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A SYNOPSIS 



OF THE 



PRACTICE OF MEDICINE 



BY 

WILLIAM BLAIR' STEWART, A.M., M.D. 

|l 

lecturer on therapeutics, late instructor in the 

practice of medicine, in the medico-chirurgical 

college of philadelphia; demonstrator 

in the philadelphia school of 

anatomy; etc., etc. 







V/762^ 



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NEW-YORK 

E. B. TREAT, 5 COOPER UNION 

1894 









Copyright 
By E. B. Treat, Medical Publisher, 

1894. 



LC Control Number 




tmp96 028668 



INSCRIBED TO MY FATHER, 

WILLIAM GRAHAM STEWART, M.D., 

NEWVILLE, PA., 

IN APPRECIATION OF 

HIS UNTIRING EFFORTS IN MY MEDICAL TRAINING. 



PKEFACE. 



Several years of instruction on the subject of the Practice 
of Medicine have led the author to prepare and present to the 
profession a brief synopsis of the subject, not with the view 
of replacing our elaborate text-books, but to give to the busy 
practitioner and student concise, accurate, and brief descrip- 
tions which will suggest outlines and practical thoughts upon 
etiology, symptomatology, pathology, diagnosis, prognosis, 
and treatment. All of the prominent authors have been re- 
viewed in text-books and medical journals, and the most ap- 
proved methods of treatment have been given prominence. 
Many drugs and systems have not been considered at length, 
not on account of their inutility, but from the fact that better 
forms of treatment have taken their place. 

The classification of diseases is open to severe criticism, but 
the author has considered it best, for the present, to adopt the 
regular arrangement and distinctly state under each subject 
its own peculiarities. The action of organic extracts and 
nuclein in pathological conditions has not been considered, 
as this subject is still under investigation. 

In conclusion, let it be remembered that the Practice of 
Medicine does not consist in the administration of drugs only, 

5 



6 PREFACE. 

but also in the exercise of good physiological, hygienic, and 
dietetic measures, combined with a deep mental impression 
and influence. 

The author desires to thank those members of the profes- 
sion who have given valuable advice and assistance in the 
preparation of this work. 

N. Carolina and Pacific Aves., 
Atlantic City, N. J. 
September 1, 1894. 



INTEODUCTIOK 



The science of medicine comprises every method used in the 
healing art, and includes the practice of surgery, obstetrics, 
and general medicine. The term practice of medicine is very 
broad in its meaning, but, as used in this work, will be lim- 
ited to such diseases and conditions as do not come prop- 
erly under the field of surgery, obstetrics, or specialism. No 
one has any moral or legal right to treat disease, nor can he 
properly understand or grasp the subject, until he is well 
versed in anatomy, physiology, histology, general pathology, 
and therapeutics. 

Any departure from the normal physiological condition is 
termed disease, and is either functional or organic. It is func- 
tional when the structure of the organ affected has not under- 
gone pathological changes which are of a permanent character. 
It is organic when the organ has undergone permanent patho- 
logical changes. Every disease is dependent upon some dis- 
tinct cause, and the removal of it will ameliorate untoward 
symptoms or produce a cure. 

Diseases are contagious when their causes are reproduced 
within the body and communicated b}^ direct or indirect con- 
tact j infectious when reproduced out of the body and com- 
municated through air, water, or food, but not reproduced in 

7 



8 INTRODUCTION. 

the body ; endemic when a certain number of cases occur peri- 
odically or constantly in the same limited territory ; epidemic 
when they spread promiscuously from one place to another, 
but not limited j sporadic when a single case occurs without 
distinct history of exposure, or independent of other con- 
ditions, and not spreading. When the onset is sudden the 
disease is acute ; when the symptoms are mild and ill-defined 
it is subacute ; and when its duration is prolonged indefinitely 
it is chronic. 

Synonyms. — Every disease or condition is known by two 
or more distinct names, and it is wise for the practitioner 
to familiarize himself with the leading terms of each as given. 

Definition. — When asked for a definition or brief descrip- 
tion of a disease, the essential or pathognomonic symptoms 
are all that is required. The definitions here given, although 
brief, will designate the condition readily. 

Etiology. — A study of the cause of disease. Certain per- 
sons are more subject to disease than others, and are said to 
have a predisposition to it which has existed from birth (hered- 
itary) or has been acquired. The children of phthisical, nerv- 
ous, insane, rheumatic, and gouty parents have a diathesis, 
predisposition, or tendency to the development of the same 
disease. Age, sex, modes of living, duties, habits, and race 1 
all influence disease. The exciting or direct causes are spe- 
cific germs, exposure, improper food and drink, dissipation, 
intemperance, excitement, worry, passion, and allied condi- 
tions. A period of incubation is the time that elapses between 
the exposure to a contagious or infectious disease and its acute 
onset. 



INTRODUCTION. 9 

Symptoms. — Those conditions which arise during the 
course of a disease and serve to demonstrate its presence, 
progress, and decline. Those symptoms which are recogniz- 
able by the patient only are subjective, and those recognized 
by the physician are objective. It frequently happens that the 
patient will not be entirely at ease for an indefinite time 
before the onset of the disease, but will present certain signs 
which are called prodromal. Pathognomonic symptoms are those 
which serve to distinguish a disease from others. Symptoms 
may subside suddenly (crisis), gradually (lysis), or suddenly 
leave one organ and appear in another (metastasis). Disease 
may terminate in death, which is recognized by a cessation of 
vital function. Complications are transitory or permanent 
symptoms which intervene in the natural course of a disease, 
and are usually unfavorable. 

Pathology. — This term, as used here, embraces a study of 
all morbid processes, their development, course, and morbid 
anatomy. It is considered from the general and special stand- 
point without long detail. 

Diagnosis. — The art of distinguishing one disease from 
another. When made directly from the symptoms and his- 
tory it is called a direct diagnosis. If made from the history 
and a detailed account of another it is an indirect diagnosis. 
A close differentiation between two intimately related or simi- 
lar diseases is termed a differential diagnosis. Diagnosis by 
exclusion is made by proving what the case cannot be, until 
only one condition is left, which is the real disease. A good 
diagnostician must be a thorough anatomist and physiologist, 
and be familiar with the minutiae of physical signs. 



10 INTRODUCTION. 

Prognosis. — The act of foretelling the course or termina- 
tion of a disease. Unless you are positively certain of what 
you speak, it is best to give a guarded prognosis, for the ways 
of nature are very peculiar, and untoward symptoms often 
arise in the most favorable cases. 

Treatment. — This subject has been considered from every 
possible side, and it is your duty to study well hygienic, die- 
tetic, and physiological methods before you rush to drugs. 
Many pathological symptoms will subside under proper care 
and a minimum of medicine, but always stand ready to use 
such remedies as the occasion demands. Let elimination 
(carrying off excrementitious products through active emunc- 
tories) form the foundation of all treatment. 

Treatment is preventive or prophylactic when it is directed 
to a prevention of the spread or communication of disease 
to others, and is accomplished by isolafon, disinfection, and 
keeping the bodily functions active and in physiological con- 
dition. 

Abortive treatment comprises the methods used to check the 
course of or abruptly terminate a disease. When treated 
symptomatically from day to day it is called expectant. 

Palliative treatment is the application of remedies for tem- 
porary relief in chronic diseases or pending a radical cure. 

AllopatMc treatment is a form in which drugs are used upon 
the principle that unlike cures ; that is, a drug must be given 
which produces a condition contrary to the disease. Very 
few physicians hold to this theory, and the word "allopathic" 
as applied to the regular system is incorrect and narrow. 

Homoeopathic treatment, a system founded by Hahnemann, 



INTRODUCTION. 11 

with the motto, Similia similibus curantur, administers drugs 
which produce symptoms like the morbid condition if admin- 
istered in health. 

Regular treatment is founded upon the broad base of clinical 
experience, and binds itself to no motto, theory, ism, pathy, 
or sect. This work is written from this broad view, and no 
method, be it introduced by any sect, is given upon a sec- 
tarian basis, but with a full knowledge that it will give certain 
results at the bedside independent of theoretical considerations. 
It is our duty to theorize in the office, society, or laboratory j 
but the sick-room demands clinical experience and knowledge. 
This should not discourage experimental research, for when 
conducted properly many new methods may be evolved. 



CONTENTS. 



PAGE 

Introduction 7 

Fevers. — The Spread of Contagious Fevers — Prophylaxis of Con- 
tagious Diseases — Antipyretic Measures — Cold Baths 17 

Continued Fevers. — Ephemeral — Influenza — Eelapsing — Epi- 
demic Cerebrospinal Meningitis — Typhus — The Plague — Ty- 
phoid 23 

Periodical Fevers. — Yellow — Malarial (Intermittent, Remittent, 

Pernicious, and Chronic) 44 

Eruptive Fevers. — Varicella — Variola — Scarlatina — Morbilli — 

Rotheln — Dengue — Erysipelas 54 

General Infectious and Contagious Diseases. — Cholera — Diph- 
theria — Pertussis — Parotitis — Tetanus — Hydrophobia — An- 
thrax — Tuberculosis (Acute, Chronic) Tuberculin — Syphilis — 

Beriberi 73 

General Non-Infectious Diseases. — Myalgia — Gout — Rachitis — 

Acute Eheumatism — Polyuria — Diabetes Mellitus 103 

Diseases of the Circulatory System 119 

Diseases of the Heart. — Introduction — Cardiac Murmurs — 
Hypertrophy — Dilatation — Fatty Degeneration — Myocarditis 
— Acute Endocarditis — Chronic Endocarditis — Mitral, Aortic, 
Tricuspid, Pulmonic Insufficiency and Stenosis — Palpitation 

Angina Pectoris — Exophthalmic Goiter 119 

Diseases of the Pericardium. — Pericarditis — Hydropericar- 

dium 139 

Diseases of the Blood-vessels. — Aneurysm — Phlebitis 142 

13 



14 CONTENTS. 

PAGE 

Diseases of the Blood. — Introduction — Ansemia (Symptomatic, 
Essential — Chlorosis and Progressive, Pernicious) — Leucaemia 
— Pseudo-leucaemia — Sapraemia — Septicaemia — Pyaemia — 
Purpura — Scorbutis — Haemophilia 145 

Diseases of the Suprarenal Capsule. — Addison's Disease 162 

Diseases of the Mouth. — Stomatitis — Aphthae — Cancrum Oris — 
Ulcers of — Thrush — Glossitis — Noma — Hemorrhage from — 
Cancer in — Salivation 164 

Diseases of the Pharynx. — Pharyngitis (Acute, Chronic, Follicu- 
lar, Tubercular, Herpetic, Sicca) — Pharyngeal Croup — Quinsy 
— Syphilis of — Herpes of Tonsils — Eetro-pharyngeal Abscess 
— Angina Ludovici 177 

Diseases of the GEsophagus. — Oesophagitis — Stricture of — Dilata- 
tion of 189 

Diseases of the Stomach. — Acute Gastric Catarrh — Chronic Gas- 
tric Catarrh — Gastritis Phlegmonosa — Toxic Gastritis — Gastric 
Ulcer — Gastric Cancer — Dilatation of — Hypertrophy — Haema- 
temesis — Gastralgia — Dyspepsia — Stomachic Vertigo 193 

Diseases of the Intestines. — Diarrhoea — Intestinal Catarrh — Duo- 
denal Catarrh — Typhlitis — Perityphlitis — Proctitis — Periproc- 
titis — Cholera Morbus — Cholera Infantum — Ileo-colitis — Acute 
Dysentery — Chronic Dysentery — Ulcers of — Cancer of — Intes- 
tinal Obstruction — Hemorrhage — Enteralgia — Constipation — 
Intestinal Worms 213 

Diseases of the Peritoneum. — Peritonitis — Ascites 239 

Diseases of the Pancreas. — Pancreatitis — Cancer of 244 

Diseases of the Liver and Appendages. — Introduction — Jaun- 
dice — Hepatic Hyperaemia — Acute Suppurative Hepatitis — 
Interstitial Hepatitis — Syphilis of — Amyloid — Fatty — Hepatic 
Cancer — Hydatids of — Acute Yellow Atrophy — Pylephlebitis 
— Catarrh of Bile-ducts — Hepatic Calculi 245 

Diseases of the Spleen. — Hyperaemia — Splenitis — Hypertrophy — 

Amyloid 261 



CONTENTS. 15 

PAGE 

The Urine. — Urine — Qualitative Urinary Analysis — Chemical Tests 263 

Diseases of the Kidneys. — Uraemia — Hyperemia — Acute Tubal 
Nephritis — Chronic Tubal Nephritis — Chronic Interstitial 
Nephritis — Amyloid — Pyelitis — Hydronephrosis — Perine- 
phritis — Floating Kidney — Eenal Cancer — Tuberculosis of — 
Eenal Calculi — Parasites (Filaria, Echinococcus, Bilharzia 
Haematobia) 266 

Diseases of the Bladder. — Cystitis — Hyperesthesia — Anaes- 
thesia — Haematuria — Paralysis 283 

Physical Diagnosis. — Introduction — Inspection — Mensuration — 

Palpation — Percussion — Auscultation — Succussion 289 

Diseases of the Nose. — Acute Rhinitis — Chronic Ehinitis — Hay- 
fever 295 

Diseases of the Larynx. — Acute Catarrhal Laryngitis — (Edema 
of the Glottis — Chronic Catarrhal Laryngitis — Tubercular 
Laryngitis — Laryngismus Stridulus — Catarrhal Croup — Mem- 
branous Croup 300 

Diseases of Bronchial Tubes and Lungs. — Bronchitis (Acute, 
Plastic, Chronic) — Catarrhal Pneumonia — Haemoptysis — Pul- 
monary Hyperaemia — Apneumatosis — Vesicular Emphysema 
— Bronchial Asthma — Pneumonia — Chronic Pneumonia — Fi- 
broid Phthisis 311 

Diseases of the Pleura. — Acute Pleurisy — Chronic Pleurisy — 

Pneumothorax — Hydrothorax 335 

The Nervous System. — Introduction — Motion — Sensation — Electri- 
cal Eeactions — Trophic Changes — Reflexes 342 

The Neuroses. — Chorea — Epilepsy — Hysteria — Thomsen's Dis- 
ease — Neuralgia — Migraine — Paralysis Agitans — Writers' 
Cramp 346 

Diseases of the Nerves. — Neuritis — Multiple Neuritis — Sciatica 

— Facial Paralysis 365 

Diseases of the Spinal Cord and its Membranes. — Spinal 
Meningitis (Acute, Chronic, Pachymeningitis) — Acute Mye- 



16 CONTENTS. 

PAGE 

litis — Poliomyelitis Anterior Acuta — Paralysis Aseendens 
Acuta — Spinal Sclerosis (Antero-lateral, Posterior, Multiple, 
Hereditary Ataxia) 372 

Diseases of the Brain and Membranes. — Acute Cerebral Menin- 
gitis — Tubercular Meningitis — Cerebral Pachymeningitis — 
Cerebral Hyperemia — Concussion — Cerebritis — Cerebral 
Hemorrhage — Cerebral Embolism and Thrombosis — Cerebral 
Abscess — Cerebral Tumors — Insolation 385 

The Psychoses. — Introduction — Mind — Insanity — General Etiology 
— Classification — Mania (Acute Delirious, Acute, Chronic) 
— Acute Dementia — Chronic Dementia — Melancholia — Moral 
Insanity — Idiocy — Cretinism— Dementia Paralytica 402 

Index 421 



A SYNOPSIS 

OP 

THE PRACTICE OF MEDICINE. 



FEVERS. 

Fever, or pyrexia, is a symptom of some general or local 
pathological process, recognized by an elevation of the normal 
body temperature, quickened circulation, increased catabolism, 
and disordered secretions, together with a -disturbance of the 
physiological functions of the part or parts affected. 

Temperature. — The average temperature of the human 
body in health is 98.6° F. or 37° C. This temperature is 
not constant in the same individual, but varies a fraction of 
one degree according to the hour of the day, the amount of 
exercise or excitement, and the character of diet. Tempera- 
ture receives various terms, according to its height : 

Subnormal temperature varies from 96° to 97.5° F. 
Subfebrile " " " 99.5° " 100.4° F. 

Slight fever " " " 100.5° " 103° F. 

High " " " " 103° " 105° F. 

Hyperpyrexia includes all temperatures above 105° F. 

Temperature is taken with a self -registering mercurial ther- 
mometer, by placing it in the axilla or groin in close contact 
with the skin j more commonly by placing the bulb under the 

17 



18 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

tongue, and closing the lips upon it, or by inserting the bulb 
into the rectum for several inches {rectal temperature). The 
last method is most reliable, but objectionable in many cases. 
To insure accuracy, allow the thermometer to remain five 
minutes before removing it. 

During fever the heart's action is accelerated, but soon be- 
comes depressed and weak ; respiration is increased ; there are 
nervous symptoms, such as headache, drowsiness, languor, in- 
somnia, delirium, coma, subsultus, and general nervousness; 
gastro-intestinal disturbances ; derangement of the functions 
of the skin, which may be hot, dry or moist ; profuse perspira- 
tion, eruptions, flushing of the face ; urine is usually high- 
colored, scanty, or profuse. Fever causes a change in the 
physiological action of every organ in the body. It is usually 
preceded by malaise, chilly sensations, a chill, rigor, or convul- 
sions, in children, lasting from a few minutes to several hours. 
If temperature is taken during a chill or rigor it will show 
pyrexia, and not subnormal temperature as would be expected. 

The acme of a fever is the highest point or critical stage. 

The fasti 'gium represents that period during which the fever 
pursues a typical course, at its height, for a long or short 
period. 

Defervescence is the period of fall or decline, and occurs by : 

(a) Crisis — a sudden fall of temperature to normal or sub- 
normal within twenty-four hours. 

(?>) Lysis — a slow fall of temperature to normal in three or 
more days. 

Convalescence is a slow or rapid return of strength after 
defervescence. 

A simple continued fever is one in which the temperature 
continues above normal for an indefinite period, with varia- 
tions of not more than one and one half degrees from day to 
day. 



FEVERS. 19 

Intermittent fever has a fall of temperature to normal for a 
short period, then rises, and thus intermits indefinitely. 

Remittent fever is paroxysmal, with distinct remissions of 
several degrees, but never intermittent. 

Idiopathic or specific fever is one which is not dependent 
upon a local affection, but upon some pathogenic microor- 
ganism whose action is not definitely known. 

Symptomatic fever is dependent upon some local trouble, and 
is caused by the absorption of ptomaines. 

Neurotic fevers are caused by a lack of inhibition in the nerv- 
ous system, nerve-lesions, and hysteria. 

Eruptive fevers are self -limited, self-protective, contagious, 
and accompanied by a rash of a specific character, always ap- 
pearing at a definite time during the course of the disease. 

Infectious fevers are dependent upon a specific germ that 
flourishes without the body; hence not communicable from 
one person to another by direct contact. Malaria ; influenza. 

Contagious fevers are caused by a specific germ which repro- 
duces itself within the body and is capable of infecting others 
by direct contact, or indirectly by contact with the germs car- 
ried on clothing, books, etc. >■ Variola ; scarlet fever. 

Epidemic fevers spread over a whole section of country, run 
for a long or short period, disappear, and may appear in some 
other neighboring community. Not stationary for any pro- 
longed period. 

Endemic fevers exist in certain communities at all times, 
limited in extent, and liable to become epidemic ; in fact, they 
are sometimes termed native fevers. 

Sporadic fevers are those isolated cases that arise independ- 
ent of epidemic or endemic causes, and are always traceable 
to some preexisting case, as they never arise spontaneously. 



20 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 



THE SPREAD OF CONTAGIOUS FEVERS. 

Every contagious and infectious disease, according to mod- 
ern pathologists, is caused by a specific microorganism or 
germ which enters the body through the respiratory, gastro- 
intestinal, or genital tract, or some abrasion of the skin. The 
germ grows and reproduces itself at the expense of the white 
cells and albuminoids either in the blood or some localized 
part of the body, and produces a poison or waste product pe- 
culiar to itself, called a ptomaine. Some time, varying from 
a few days to several weeks, must elapse before the actual 
onset of the disease, during which the germs are coming 
into activity, constituting the period of incubation or invasion. 
These living germs constitute the actual means of contagion, 
and always originate from that special disease. Contagion 
is most active during the height and decline of a disease, as 
at that time the excreta, urine, expectorated matter, exhala- 
tions, desquamating epithelium, or discharges from vesicles, 
pustules, or open sores contain the germ in its most active 
state. Thus it is possible to convey the germ, by direct con- 
tact with the sick, on clothing, articles of furniture, books, 
and other things that ha ye been used by or about them. 
It must be remembered that the germ of scarlatina, variola, 
and some other diseases will lie dormant in clothing for many 
years, and still retain its full power of infection. All persons 
are susceptible to contagious diseases, but more especially 
children and those debilitated by sickness, confinement, and 
bad hygiene. One attack usually affords immunity from a 
second ; hence self-protective to a degree. Second and third 
attacks may occur in the same person. 



FEVERS. 21 



PROPHYLAXIS OF CONTAGIOUS DISEASES. 

There are certain definite rules applicable to the prevention 
of all contagious and infectious diseases, which will be sum- 
marized in this section. 

Isolation. — The first imperative measure. If possible, select 
a large, well- ventilated room at the top of the house — south- 
ern or western exposure preferable. Remove all unnecessary 
and upholstered furniture, curtains, clothing, rugs, pictures, 
and heavy carpets. Put the patient in this room and allow 
no one to enter except the nurses and physicians — always 
instructing them to avoid contact with other members of 
the family, and to stay in that part of the house, unless 
clothing has been previously changed and an antiseptic bath 
taken. 

Disinfection. — All excreta, vomited and expectorated mat- 
ter must be thoroughly and freely mixed with chloride of lime, 
Piatt's chlorides, or concentrated carbolic acid, and either 
buried or thrown into the sink after standing for one hour. As 
far as practicable use cotton and old linen for the discharges, 
and burn at once. Soiled clothing and handkerchiefs should 
be placed in an antiseptic solution before removal from the 
room, and then boiled for six hours before they are used 
again. It is a wise precaution to wipe the floor and furniture 
daily with an antiseptic wash. A sheet, wetted with an anti- 
septic solution, is often hung over the door as an additional 
safeguard. Unused food should always be destroyed. Keep 
the windows open to afford free ventilation, taking care to 
avoid direct draughts. Bathe the patient frequently with anti- 
septic washes (acid bichloride of mercury, jjp). During 
convalescence, a daily scrub-bath should be given, and, as a 
final means, before going into other parts of the house, thor- 



22 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

ouglily shampoo the hair with antiseptic washes and change 
all clothing. 

Disinfect the room by scrubbing the floors, washboards, fur- 
niture, and walls with acid bichloride of mercury; scraping, 
calcimining, white- washing, or papering the walls and ceiling ; 
thoroughly boiling all bed-clothing and linen for six hours ; 
and destroying, by fire, books and toys used by the patient. 
The fumes of burning sulphur are frequently used, but it 
must be remembered that sulphur vapor is antiseptic only in 
the presence of moisture; hence it is well to have the room filled 
with steam when this method is used. 



ANTIPYRETIC MEASURES. 

Fever is diminished by hygienic and dietary means, internal 
medication, and the local application of cold. 

Hygiene and Diet. — All persons with slight or high fever 
should be placed in bed in a cool, well-ventilated room, and 
be freed from all business and family cares and worries. 
Light, nutritious diet (milk, broths, and refrigerant drinks) at 
regular intervals. This is the physiological method, and fa- 
vors Nature in her cure, but does not in itself lessen fever. 

Internal Medication. — Aconite, veratrum, antimony, digi- 
talis, colchicum, gelsemium, and strophanthus act upon the 
circulatory system. Quinine, cinchona salts, salicjlates, car- 
bolic acid, camphor, and phenacetin reduce fever by lessen- 
ing active catabolism. Acetanilide, nitrous ether, alcohol, 
and antipyrin act by dilating the capillary vessels of the skin, 
thus increasing radiation of heat. 

Local Application of Cold — Sponging. — In cases of mode- 
rate or high fever the body is sponged all over with cold or 
tepid water, prolonging the operation as long as it is comfort- 



FEVERS. 23 

able to the patient, exercising care not to chill. This is a 
convenient and efficient means, in mild cases, to reduce tem- 
perature one or two degrees. 

Wet-pack. — This consists of wringing sheets out of ice-cold 
water and wrapping them around the whole body, and repeat- 
ing the process every minute or more until the condition of 
hyperpyrexia is overcome. Some wrap patient in a wet sheet 
and pour cold water over it. 

Ice-hags or cracked ice are often applied to one or more 
parts of the body, and allowed to remain until the desired 
local results are obtained. 

Cold Baths. — The Germans use this method very extensively 
in treating typhoid fever. The water is prepared in a bath at 
a temperature of 60° to 80° F. ; the patient is gently immersed 
in it for five, ten, or twenty minutes, according to indications. 
Sometimes iced water is gradually added to water at 80° F., 
until it falls to 60° or 70° F. When patient is removed he 
should be rubbed gently with a soft, coarse towel, covered 
warmly, aiid, if weakened, stimulants must be given. A cold 
bath is used whenever the temperature reaches 102° F., and 
reduces temperature three to five degrees. Patients threatened 
with pneumonia, hemorrhage, or collapse should not be placed 
in a cold bath. Repeat baths as often as necessary. 



CONTINUED FEVERS. 

EPHEMERAL FEVER. 

Synonyms. — Simple continued fever ; febricula ; simple es- 
sential fever ; irritative fever ; synochus. 

Description. — Children and adults are subject to the influ- 
ences of mental and physical exhaustion, over eating and 
drinking, excitement, exposure to heat and cold, and often de- 



24 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

velop a slight fever with no definite or constant pathological 
lesion. It begins with a slight chilly sensation, chill, rigor, 
or convulsion, together with general malaise, slight headache, 
anorexia, thirst, and coated tongue. Temperature gradually 
or quickly runs from 101° to 104° F. ; pulse rapid ; urine 
scanty and high-colored ; slight delirium if the temperature 
is high. These symptoms continue from one to ten days, and 
subside by lysis or crisis. 

Treatment. — Rest in bed : a light diet of milk, meat broths, 
rice-milk, sago, and acidulated drinks. Sponge the body fre- 
quently with tepid or cold water and alcohol. Triturated 
calomel, one-tenth grain, every hour, until free action is ob- 
tained. In addition, you may give a mild fever mixture. 

Tr. aconiti radicis fll. xvj. 

Liq. ammonii acetatis f 1 jss. 

Syrupi aurantii floratis . . . q. s. ad. f I ij. 
M. Signa. One teaspoonful every two hours, as necessary. 

Remove every possible cause, and, during convalescence, ad- 
minister tonics of iron and quinine if indicated. 

INFLUENZA. 

Synonyms. — Epidemic catarrh; la grippe; "the grippe"; 
Russian influenza. 

History and Etiology. — Influenza is a disease that has 
been known to man from most ancient times, occurring among 
all nations at irregular intervals. No definite records of these 
epidemics exist previous to the sixteenth century. Fagge re- 
cords eleven epidemics in the sixteenth century, sixteen in the 
seventeenth, eighteen in the eighteenth, and ten between the 
years 1800 and 1850. A very severe epidemic spread over 
Europe, America, and Asia during the winter of 1889 and the 



FEVERS. 25 

spring of 1890, causing a great mortality, and leaving thou- 
sands of people with its sequelae. In 1891 and 1892 the dis- 
ease was mildly epidemic in parts of the United States, China, 
and Japan. It seems to affect cattle as well as man, and the 
great epidemic of epizootic in horses, in the year 1872, in New 
York, is claimed to have been due to this poison or a similar 
one. Each epidemic seems to differ from the preceding one 
in course, sequela?, and mortality. 

There is a prevalent idea that influenza is always a fore- 
runner of Asiatic cholera, from the fact that the latter has fre- 
quently followed the track of influenza. In July, 1892, cholera 
was epidemic in Russia, and followed the track of the recent 
epidemic of influenza and made its appearance in Paris. These 
are given only as facts, but no reliable deductions can be drawn 
from present statistics. 

Influenza is undoubtedly caused by an aerobic germ which is 
transmitted by the air. It is infectious and, possibly, slightly 
contagious. Some pathologists claim that they have found 
the germ of influenza, and that it is the smallest known, and 
flourishes in the mucous membrane of the respiratory tract ; 
but it remains to be confirmed. All persons, strong and weak, 
are attacked, but more especially those suffering with chronic 
diseases. Heat and cold do not appear to influence the spread 
of influenza, for it exists in the coldest parts of Russia and 
in the warmest tropical climates. 

Symptoms. — Onset is sudden with a distinct chill, an attack 
of syncope, or may be preceded by slight headache, giddiness, 
anorexia, and general malaise. Temperature rises rapidly in 
a few hours from 102° to 104° F. ; intense aching pain in the 
head, back, arms, and" legs ; skin may be dry and hot, or cov- 
ered with profuse perspiration ; mild delirium in cases with 
high temperature ; great lassitude ; photophobia ; conjunctivae 
are congested and lachrymation is profuse ; free, clear, watery 



2G A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

discharge from the nose ; occasional epistaxis ; sneezing and 
a dry, hacking, irritating cough ; hoarseness j tongue is coated 
with a heavy white fur; pulse increased, with a tendency 
to weakness • skin is often hyperaesthetic. Stomach is irri- 
table j nausea or vomiting • epigastric tenderness or pain ; 
may be slight haamatemesis ; bowels constipated or in state of 
diarrhoea. 

These symptoms continue four or five days, and subside by 
lysis or crisis, leaving the patient in a condition of extreme 
prostration and debility, out of all proportion to the duration of 
the disease. Convalescence is slow, and lasts from one week to 
one year. In many cases, just as in typhoid fever, the nor- 
mal strength or power of endurance is permanently impaired. 
Pneumonia is the most frequent complication, either lobular 
or lobar. The joints often become inflamed in certain epi- 
demics (1889-90). 

Peculiar Manifestations. — The onset is usually the same, but 
certain symptoms are more marked in some than in others. 
It assumes a catarrhal form when the respiratory tract is 
affected ; a gastro-intestinal form when that tract is most in- 
volved ; a nervous form when the manifestations are principally 
nervous, with slight involvement of gastro-intestinal and re- 
spiratory tract. Any of these forms may exist alone or in 
combination. 

Diagnosis. — Made from its being epidemic : sudden onset ; 
peculiar catarrhal, gastric, and nervous symptoms ; extreme 
prostration ; sequela?, and slow convalescence. 

Prognosis. — In previously health} 7 persons influenza, if prop- 
erly guarded, is not fatal. Complicated cases are uncertain. 
Among old and debilitated persons, chronic cases of Bright's 
disease, tuberculosis, cancer, heart-diseases, and in very young 
children the mortality is high — often fifty to seventj'-five 
percent. An epidemic of influenza always leaves its after- 



FEVERS. 27 

effects so thoroughly impressed on a community that it takes 
years to regain its normal condition of immunity from other 
diseases. 

Treatment — Prophylaxis. — As in all diseases, attend to hy- 
giene. It seems that no precaution will prevent an attack, 
not even the much-abused daily dose of quinine and whisky, 
which seems to favor rather than retard its invasion. Dur- 
ing an epidemic be regular in hours of sleep, work, and rec- 
reation. Avoid all unnecessary stimulation and drugging; 
eat nothing but substantial, nutritious, wholesome, and easily 
digested foods ; avoid carousals, unnecessary fatigue, worry, 
and venereal excesses ; keep the bowels active every day, and 
avoid a sedentary, indoor life ; sleep in well- ventilated rooms. 
If any preventive measures will avail, these will ; if they do 
not you will be in the best possible condition to abort or en- 
dure an attack. 

Active Treatment. — Put the patient in bed and keep him 
there until convalescence is well advanced ; darken the room ; 
bathe frequently with tepid water. Pain is the leading symp- 
tom, and can be relieved by two or five grains of phenacetin 
every two or three hours, given with hot water ; or pill acet- 
anilide comp., every half -hour until relieved ; or the salicylates. 

Pill acetanilide comp : 

Acetanilide. 

Quininse bisulphatis aa. gr. j. 

Cocainge hydrochloratis gr. t§-. 

M. Fiat pilula vel tablet., compress., No. 1. 

Sodii salicylatis 3 jss. 

Liq. ammonii acetatis f I jss. 

Syr. aurantii nor q. s. ad. f § ij. 

M. Signa. One teaspoonful every two hours until relieved, 
then every three or four hours as necessary, 



28 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

These combinations relieve pain, reduce fever, are antisep- 
tic and favor diaphoresis. Apply ice to the head, if desirable. 
Follow the relief of pain by the administration of triturated 
calomel, one-tenth grain, every hour until free action is ob- 
tained. Calomel will also relieve nausea and irritation of the 
stomach and bowels. 

Cough and catarrhal symptoms are treated as acute laryn- 
gitis and bronchitis. Avoid all depressants, and administer 
tonics as indicated. Let the diet be most nutritious, liquid 
and non-irritating albuminoid products — milk, wine-whey, 
broths, beef -extracts, boiled rice, or rice-milk. During conva- 
lescence give tonics of cinchona, iron, arsenic, and strychnine. 
For a persistent cough, following an attack, nothing is better 
than malto-yerbine, one dram, three or four times daily. Com- 
plications must be met as they arise. 

RELAPSING FEVER. 

Synonyms. — Febris recurrens; famine fever; bilious re- 
lapsing fever. 

Definition. — An acute, contagious, self-limited, epidemic 
fever, recognized by a sudden onset with chill, high fever, pains 
in the head and muscles, jaundice, and vomiting. Lasts for 
seven days ; has a distinct remission of six or seven days, and 
a return of all symptoms as at first. 

Etiology. — Caused by the Spirocliceta Obermeieri. Conta- 
gious. Development is favored by filth, crowding, bad hy- 
giene, and lack of proper diet. Period of incubation is one to 
fourteen days. 

Symptoms. — Onset is sudden, without prodromal symp- 
toms. Chill or rigor followed by high fever, 102° to 106° F. ; 
violent headache ; sharp, shooting pains in the muscles of the 
legs, back, and arms ; nausea and vomiting ; epigastric tender- 



FEVERS, 29 

* 

ness ; liver and spleen are swollen and tender to pressure j 
anorexia, great thirst, and insomnia ; tongue is coated with a 
thick white coating. 

As temperature increases, pains and other symptoms are 
aggravated. Jaundice frequently occurs on the third or fourth 
day and is often pronounced. Urine contains bile-pigment, 
decrease of the chlorides, and may show a trace of albumin. 
Herpes labialis is a frequent complication ■ delirium is a late 
symptom. On the seventh day crisis comes suddenly with 
profuse perspiration and rapid fall of temperature to normal 
or subnormal. Patient feels well, except weak. Convalescence 
takes two or three days, and is apparently complete. 

On the fourteenth day from the onset the attack repeats 
itself, and all symptoms return. Crisis occurs in three to five 
days. Relapses may occur four or five times, or not at all. 

Complications. — Pneumonia ; pleurisy ; intense hyperemia 
or rupture of the spleen; jaundice, acute or chronic; in- 
flammation of the salivary or cervical glands ; epistaxis or 
hamiatemesis. 

Pathology. — Undoubtedly due to the Sjriroclueta Obermeieri, 
a spiral or corkscrew-shaped filament found in the blood dur- 
ing the height of the fever, and entirely absent during the 
interval. These spiral filaments multiply rapidly, possess a 
rotary spiral motion, and are about -5^0 to toVo i ncn m length. 
Spleen and liver are enlarged and hyperamric. 

Diagnosis. — The positive diagnostic sign is a microscopical 
demonstration of these spirilla? in the blood. 

Prognosis. — Not commonly fatal; death is most common 
during the height of a first attack or at crisis. Convalescence 
is prolonged and slow. 

Treatment. — Rest in bed, with free ventilation, isolation, 
and best hygienic surroundings. Give a diet such as is given 
in typhoid fever, during the attacks ; but in the intervals give 



30 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

good, rich milk, rare beef, soft boiled eggs, and ripe fruits. 
Begin treatment with a free calomel purge. Sponge the body 
with tepid water and alcohol every few hours ; give cold water 
and cracked ice. 

Infusion of digitalis, f 3 j, with acetate of potash, gr. v, every 
four hours. Pill acetanilide comp. (form, p. 27), every hour 
for five or six hours, often relieves muscular pains and head- 
ache. Cold baths for hyperpyrexia. If pains are very severe, 
administer morphina sulph., gr. x, and atrophia sulph., gr. y^o, 
hypodermically, to be repeated in half an hour if necessary. 
Carbolic acid, iodine, sulphocarbolate of zinc, and salol are 
claimed as excellent antiseptics and of possible use when in- 
ternally administered. Stimulate freely during crisis or as 
demanded. Avoid all depressants. During convalescence give 
tonic treatment. Enforce prophylactic measures to prevent 
contagion. 

EPIDEMIC CEREBROSPINAL MENINGITIS. 

Synonyms. — Spotted fever ; cerebrospinal fever ; cerebro- 
spinal typhus 5 apoplectic cerebral typhus ; epidemic meningi- 
tis. The Germans call it Geniclckrampf and Nackenstarre. 

Definition. — An acute, specific, epidemic, malignant, infec- 
tious fever, recognized by spasmodic muscular contractions 
of the muscles of the neck and back, hyperesthesia, together 
with a peculiar eruption (not constant). 

Etiology. — It is due to a round micrococcus called Micro- 
coccus intracellulars meningitidis, usually occurring in groups 
of two (diplococci). Epidemic and not contagious. Most com- 
mon in winter among young adults. Acute diseases predis- 
pose one to attacks during epidemics. Period of incubation is 
nearly seven days. 

Symptoms. — Prodromal symptoms are headache, loss of appe- 
tite, malaise, and general pains. Onset is sudden, with a severe 



FEVERS. 31 

chill or rigor, violent pain in the head, persistent vomiting, 
and a feeling of giddiness. Photophobia and intolerance of 
noise j pupils are contracted at first, but dilated later. Con- 
vulsions often appear early ; delirium. Headache is so severe 
that the patient cries out with it. There is stiffness and sore- 
ness in the muscles of the neck and back during the first and 
second days, which soon assumes a severe form, with tetanic 
convulsions, in which the head is drawn back, and frequently 
accompanied by oposthotonos. The body may assume a straight, 
rigid state — orthotonos. Patient lies on side, with legs flexed, 
on abdomen. Pains in the joints are often severe; skin is 
hyperaesthetic ; quantity of urine is profuse. Temperature 
varies from 102° to 107° F., and assumes no regular type. 
Deafness, loss of sight and smell, temporary or permanent. 

Eruption appears from the third to the sixth day, and is 
either herpetical, on the face and ears, or a diffuse urticaria, 
erythema, or purpura. The only peculiarity of the eruption 
is the fact that it occurs symmetrically on different parts of 
the body. Disease reaches its height about the tenth day, and 
declines by lysis or assumes a more serious form, resulting 
in death. Convalescence is long, and often extends over many 
months. Among serious sequela? are loss of hearing, sight, 
and smell ; deaf -mutism ; headache that persists for years after- 
ward ; progressive emaciation ; epilepsy or special paralyses. 

Fulminant or foudroyant cases are those malignant attacks 
where the patient dies a few hours after the onset, and occur 
most commonly in the early part of epidemics. 

Abortive cases are those whose symptoms are not well de- 
fined, and are followed by recovery after a few days in bed, 
or a short period of indisposition ; most common during the 
decline of an epidemic. 

Hysterical cases occur in excitable, nervous women and chil- 
dren, are never fatal, and are easily distinguished by physical 
examination. 



32 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Pathology. — The disease is caused by a diplococeus called 
Micrococcus intracellular is meningitidis, which, by some unknown 
selective action, produces an inflammation of the meninges at 
the base of the brain and medulla oblongata, involving the 
ventricular structures. Post-mortem examination shows an 
exudation of lymph and pus on the pons, chiasma, sulci, large 
vessels, posterior part of the medulla, and the ventricles. 
Congestion of the base of the lungs ; hyperemia of the liver, 
spleen, and kidneys. Rigor mortis is prolonged, and staining 
of the body marked. 

Diagnosis. — Typhoid fever does not begin so abruptly ; has 
no high rise of temperature during the first and second days • 
time and character of eruption are different, and it runs a 
different course. 

Simple sporadic meningitis has no loss of special senses; 
symptoms less marked; no muscular contractions of severe 
type ; absence of peculiar eruption, and is not epidemic. 

Prognosis. — Must be guarded. Simplest cases often be- 
come most severe. Relapses are very common. A mean 
mortality is given as forty percent. Always advise as to 
possible sequela?. 

Treatment. — Treat on the same principle as simple menin- 
gitis, q. v. Observe best hygienic surroundings to prevent 
its spread. Treat complications and sequela? as demanded. 



TYPHUS FEVER. 

Synonyms. — Camp fever; jail fever; ship fever; putrid 
fever ; stupid fever. 

Definition. — An acute, contagious, epidemic fever, recog- 
nized by a sudden onset, high fever, great depression, stupor, 
and the appearance of a petechial eruption on the fifth day. 



FEVERS. 33 

Etiology. — The primary cause is a distinct germ. It is 
both epidemic and endemic. Close crowding, close confine- 
ment, filth, decomposing vegetable matter, nncleanliness, im- 
proper diet, and general debility are predisposing causes. It 
often breaks out in overcrowded, poorly ventilated jails, ships, 
and tenement-houses. Most common among the poorer classes. 
It is highly contagious. 

Symptoms. — For several days prior to the onset there are 
tired feelings, headache, loss of appetite, dizzy and chilly sen- 
sations. Onset is heralded by a chill, nausea, vomiting, and 
high fever, 102° to 104° F., on the first or second day. Pulse 
and respiration increased; tongue coated with a yellowish- 
white coating ; constipation ; throbbing headache, face flushed, 
and photophobia. Urine is scanty, high-colored, and often 
contains albumin. On the fifth day a petechial or mulberry 
rash appears on the abdomen, chest, arms, and legs j little or 
no eruption on the face and neck. The eruption consists of 
petechial spots which do not disappear on pressure and do 
not come out in separate crops ; most pronounced from the 
seventh to the tenth day, when it begins to fade, and finally 
disappears between the fourteenth and twentieth days. 

A characteristic symptom is the peculiar blank facial expres- 
sion ; contracted pupils ; absolute indifference to conversation 
and surroundings. All symptoms reach their height about 
the second iveek, when there is continual delirium of a low 
muttering type, or it may be wild and maniacal. Coma may 
supervene, together with subsultus tendinum, involuntary 
passage of urine and faeces. Tongue, during later stages, is 
dry, brown, and fissured ; teeth and lips covered with sordes. 
There is a peculiar mouse-like odor about these cases, most 
marked during the second or third week. Bed-sores are com- 
mon. 

Crisis comes about the fifteenth day, when the temperature 



34 



A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



falls nearly to normal or subnormal in twenty-four hours. 
All other symptoms subside, leaving the patient very weak, 
pale, and emaciated. Death may ensue at crisis from paral- 
ysis of the heart or complications of pneumonia, coma, or 
relapses. 

Pathology. — Typhus fever is due to a germ the exact nat- 
ure and action of which are not determined. There are no 
constant pathological lesions by which to determine where 
the disease is central. Post-mortem examination shows the 
general muscular tissues, including the heart, in a state of 
fatty degeneration and quite friable. Blood is thin, dark in 
color, and forms imperfect clots. Liver, spleen, and kidneys 
are enlarged and friable. 



DIAGNOSIS. 



TYPHUS FEVER. 



Short prodromal symptoms. 
High fever during first day, irregu- 
lar in course. 
Constipation. 

Slight general abdominal tender- 
ness. 

Petechial eruption on fifth day ; not 
in successive crops ; not influ- 
enced by pressure ; covers whole 
body. 

Ends in three weeks by crisis. 

Peculiar mouse-like odor present. 

Highly contagious. 

Early delirium and cerebral symp- 
toms. 
No involvement of Pyer's patches. 



TYPHOID FEVER. 



Long prodromes, with epistaxis. 
Fever rises slowly and regularly for 

seven or eight days. 
Persistent, pea-green diarrhoea. 

Marked tenderness in right iliac 

fossa. 
Eruption on seventh day ; comes in 

crops ; disappears on pressure ; 

limited to abdomen, chest, and 

back. 

Ends in five or six weeks by lysis. 

No characteristic odor. 

Infectious ; possibly slightly con- 
tagious. 

Late delirium and cerebral symp- 
toms. 

Pyer's patches the seat of disease. 



Prognosis. — Occurring in hearty, strong individuals, it is 
good. Quite fatal in young children, aged and debilitated 
persons. 

Treatment. — Isolation and the strictest antiseptic measures 
are imperative. Ventilate the sick-room freely, destroy all 



FEVERS. 35 

excreta by fire, and follow prophylactic measures as indicated 
on page 21. Constantly watch patient to prevent accidents 
during delirium. Establish free action of the bowels by full 
doses of calomel and ipecacuanha. No known remedy will 
abort or shorten the disease. Soldi, gr. v, or sulphocarbolate 
of zinc, gr. iij— v ? every four hours through the whole course, 
seems to mitigate unfavorable symptoms by its possible 
antiseptic action. Reduce fever by cold baths, cautiously ad- 
ministered as often as necessary. Avoid depressants; stimu- 
late freely. Quinine is of doubtful utility. 

Feed at regular intervals with milk, beef -extracts, whites of 
eggs in cold water, or good broths. Carbonated or alkaline 
waters can be used at liberty. Sponge the body several times 
daily with cold water and acid bichloride of mercury. Admin- 
ister carbonate of ammonia at crisis to prevent heart-failure. 
Watch the bladder closely to avoid retention of urine. Ice 
applied to the head will relieve headache. Chloral is the best 
remedy for coma vigil. Meet complications as they arise. 



THE PLAGUE. 

Synonyms. — Oriental plague ; Levantine plague ; bubonic 
plague. 

Etiology. — Due to some specific microorganism 5 conta- 
gious; self -protective. Virus is carried on clothing and 
merchandise; warm, damp weather favors its development; 
occurs principally in low, marshy districts. Filth, poverty, 
overcrowding, and bad hygiene favor it. Period of incubation 
is from three to seven days. 

Description. — The plague was most active during the mid- 
dle ages, but has since occurred in Oriental countries as an 
epidemic at irregular intervals. During 1892 it was present 



36 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

in some parts of the East, and at this time (1894) is epidemic 
in China, and the mortality is very great. 

There is a short prodromal period of malaise, depression, 
headache, anorexia, attacks of giddiness or syncope, and slight 
fever. Onset is preceded by chilly sensations or a chill, fol- 
lowed by rise of temperature to 103° to 107° F. ; rapid pulse, 
120 j tongue moist and red at first, but soon becomes covered 
with a brown coating as in typhoid fever ; a general typhoid 
condition soon follows. Death may occur in one or two days, 
and is frequently preceded by a petechial eruption, haematuria, 
and heematemesis. About the third day buboes form in the 
groin, axilla, or neck, and vary in size from a pigeon's egg to 
a hen's egg. When buboes form, fever and delirium lessen ; 
skin is covered with perspiration • pulse falls to 90 or 100. 
Buboes often break spontaneously, and pursue a long course 
of suppuration. Carbuncles not infrequently appear in large 
numbers on the nates, neck, back, and arms. Convalescence 
is very slow and tedious. Pneumonia, dropsy, paralysis (gen- 
eral or local), pyaemia, or mental troubles may complicate or 
follow. 

Pathology. — Due to a specific germ which seems to develop 
best in low, marshy districts during hot, damp weather. The 
germs have a selective action for the lymphatic system, in 
which they cause inflammation and suppuration. After death 
the spleen is enlarged, soft, friable, and dark in color. Serous 
membranes are blood-stained and ecchymosed. Internal lym- 
phatic glands are enlarged, swollen, and in a state of suppura- 
tion. 

Diagnosis. — An epidemic of the plague is diagnosed by the 
high fever, appearance of buboes and carbuncles in large 
numbers, and the great mortality. It is frequently mistaken 
for typhus fever, to which disease it bears some resemblance. 

Prognosis. — The mortality during past epidemics ranged 



FEVERS. 37 

from sixty to ninety percent. Modern antiseptic treatment 
may diminish mortality. 

Treatment. — Isolation and preventive treatment, as given 
on page 21. Most nutritions, stimulating, and sustaining diet. 
Avoid depressants. Pill acetanilide comp., every half -hour or 
hour (form, p. 27) ; salol, gr. v, every four hours ; sulphocarbo- 
late of zinc, gr. v, every four hours, with a view to antisepsis. 
Infusion of digitalis and acetate of potash as indicated. Cold 
baths to reduce temperature. Constant applications of anti- 
septic lotions to "buboes and early incision. Meet complica- 
tions and give tonic treatment from first until convalescence 
is complete. 



TYPHOID FEVER. 

Synonyms. — Enteric fever; entero-mesenteric fever; ab- 
dominal typhus. 

Definition. — An acute, infections, self -limited fever, recog- 
nized by long prodromes, epistaxis, abdominal tenderness, 
diarrhoea, enlarged spleen, marked nervous symptoms, a petech- 
ial eruption appearing in crops on the abdomen on and after 
the seventh day, and a characteristic temperature-chart rising 
gradually by regular intervals for seven days, remaining sta- 
tionary for one or two weeks, and declining by lysis. 

Etiology. — It is caused by a specific, pathogenic germ called 
the bacillus typhosus, which is capable of reproduction in de- 
composing vegetable or animal matter, or within the large 
and small intestines, when in a condition of lowered vitality. 
Among predisposing causes is the use of infected drinking- 
water, milk, vegetable and animal food ; overcrowding, filth, 
prolonged hot and diy weather following or preceding a wet 
spell. May be derived directly from the excreta of patients. 



38 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Epidemic at times. Never originated de novo — spontaneous ■ 
generation is impossible. Young adults are most susceptible. 
It is not self-protective, and may occur an unlimited number of 
times in the same person. Period of incubation varies from 
one to four weeks. 

Symptoms. — One to four weeks preceding the onset, an 
uncertain period of incubation, there are certain characteristic 
prodromal symptoms. Patient complains of a general tired 
feeling with slight muscular soreness, pain in the back and 
bones, headache, lack of usual energy, loss of appetite, and 
restless sleep, disturbed by dreams ; attacks of vertigo or gid- 
diness ; occasional mild or profuse epistaxis ; nervous and irri- 
table ; cold, creepy feelings ; tendency to diarrhoea (at times 
marked constipation) • a flushed, feverish appearance toward 
evening, and floating spots before the eyes. 

Onset is variable. Patients sometimes take to their beds 
from exhaustion or debility when the temperature begins to 
rise. Others have a distinct chill or rigor followed by a slight 
rise in temperature, severe headache, and diarrhoea. Pulse is 
quick, soft, and may be dichrotic • respiration increased ; short, 
hacking, unsatisfactory cough; tongue is red at the tip and 
edges, with a brown coating in the center. Evening tempera- 
ture rises one and one half to two degrees every day, and, in the 
morning, falls one degree below the temperature of the pre- 
vious evening. This continues for six or seven days until 
104° or 105° F. is reached, when it continues about the same 
height for seven or ten days, with about one degree between 
morning and evening temperature. 

Between the seventh and tenth days the disease assumes its 
typical form. Patient is dull and listless ; picks at the bed- 
clothing for imaginary objects; has low, muttering delirium; 
headache ; tongue is dry and red on sides and edges, a red 
line running down its center, and a white coating on each 



FEVERS. 39 

side. Teeth and gums are covered with thick sordes ; profuse 
epistaxis may occur. Diarrhoea continues, and assumes a con- 
dition similar to green-pea soup, and is very offensive ; spleen 
is enlarged and tender ; abdomen prominent, tympanitic, with 
gurgling, rumbling, and crepitation, and marked tenderness 
in the right iliac region. 

Eruption. — About the seventh day a characteristic eruption 
appears on the abdomen, chest, and back in the form of rose- 
red spots, varying from one to four lines in diameter, isolated, 
and disappearing on pressure. These spots come in successive 
crops of five to twenty, each crop fading in about four days, 
and so continuing until the twenty-first day of the disease, or 
disappearing at death. 

At the end of the second week intestinal hemorrhages are 
most prone to occur, usually indicated by a sudden fall in 
temperature, great pallor or syncope, and a discharge of clotted 
or bright-red blood from the bowels. Sloughed portions of 
the intestines may be passed. Urine is scanty, high-colored • 
specific gravity high j late increase of urates • albumin may 
be present ; retention or passed involuntarily. SubsuUus is a 
marked late symptom. Temporary or permanent deafness. 

Between the twelfth and fourteenth days, it declines by lysis. 
Temperature falls regularly. The morning temperature falls 
one degree each day, but the evening temperature remains 
about the same for several days, and then declines as it rose. 
Fever is liable to intermit and remit before convalescence 
begins. 

The fastigium or height of the disease lasts from the seventh 
to the twelfth or fourteenth day, but there are cases where it 
appears to run for several weeks. Such cases enter what 
Wunderlich calls an ambiguous period. Relapses are prone to 
recur. Pneumonia frequently complicates typhoid fever, and 
is heralded by a sudden fall in temperature, followed in a few 



40 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

hours by a sudden rise. Perforation is usually attended by 
profuse hemorrhage, collapse, and peritonitis. Bed-sores are 
common in later stages. Convalescence is long, tedious, and 
slow. 

Walking typhoid fever is a term applied to those cases which 
pursue an apparently mild or insidious course during the first 
and second weeks, in which time the patient goes about busi- 
ness in a listless way, not feeling sick enough to consult a 
physician. These cases often terminate fatally or with most 
serious consequences, owing to a lack of proper diet during 
the earlier stages. Walking typhoid does not imply mild 
typhoid by any means. 

Pathology. — Typhoid fever is caused by the bacillus typho- 
sus, which flourishes in the large and small intestines, when in 
a state of lowered vitality, attacking the solitary glands and 
glands of Pyer. These germs grow at the expense of sur- 
rounding tissues, produce ptomaines, and act as irritants, caus- 
ing congestion and inflammation of the structures named. As 
a further result of irritation, intestinal secretions are increased, 
and, when mixed with ptomaines and waste products, cause 
pea-green, offensive diarrhoea. Furthermore, these ptomaines 
are absorbed, carried into the general circulation, and by their 
action on the various nerve-centers produce systemic condi- 
tions — fever, delirium, stupor, and headache. Pyogenic germs 
soon complicate the action of the bacillus tyj)hosus (a mixed 
microbic infection), and the simple inflammation of Pyers 
glands assumes an ulcerative type, often resulting in perfora- 
tion of the intestine, with hemorrhage from eroded capillaries 
or vessels, and peritonitis. Post-mortem shows Pyer's glands 
swollen, elevated, red, and ulcerated ; mesenteric glands en- 
larged, inflamed, and ulcerated ; enlarged, dark-red, friable 
spleen; kidneys and heart are soft and granular; lungs are 
congested. 



FEVERS. 41 

Diagnosis. — There are seven diagnostic points, viz. : (1) long 
prodromes ; (2) epistaxis ; (3) peculiar temperature ; (4) ab- 
dominal symptoms — gurgling, tympany, tenderness in right 
iliac region, and diarrhoea ; (5) characteristic eruption on sev- 
enth day j (6) nervous symptoms ; (7) prolonged convalescence. 
From Typhus Fever, see p. 34. 

Prognosis. — Must always be guarded. Mild cases usually 
recover in four to six weeks. Convalescence is slow, and 
lasts from four weeks to a year. Latent tuberculosis is often 
brought into activity by an attack. Hemorrhage, perfora- 
tion, and complications are bad signs. 

Treatment. — Follow strictest prophylaxis and antisepsis, as 
indicated on page 21. 

Rest in bed during the whole course of the disease. Patient 
should use a bed-pan and not be allowed to rise. Excitement, 
noise, and worry must not be permitted. A nurse should be 
in constant attendance day and night ; temperature should be 
noted two or three times daily, and the greatest care taken to 
properly dispose of all excrementitious products. Watch the 
bladder to detect retention of urine. 

Diet — Probably no more important subject demands our 
attention than that of diet. Solid foods must be absolutely for- 
bidden, as they irritate the intestinal mucous membrane and 
produce ulceration and perforation. Let diet consist of milk 
and lime-water ; animal broths ; beef-extracts ; corn-starch, 
soft boiled rice, tapioca, or sago, provided they have been 
passed through a line sieve to remove solid particles ; white 
of egg given in ice- water with a pinch of salt. Avoid oat- 
meal. Feed at regular intervals of four hours, and never give 
large amounts at one time. Brandy may be given with milk 
if desired or indicated. Pig's-feet jelly (provided it has been 
strained to remove solid particles), given with vinegar, affords 
slight variety. Wine-whey is good. The general rule for 



42 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

diet is to avoid all solid, indigestible, or irritating articles, 
and give liquids or jellies of a bland, nutritions, nnirritating 
quality. 

If seen before or at the onset, administer a free cathartic 
of calomel (one-quarter grain triturate, every half -hour, until 
free catharsis results) or a full dose of castor-oil. Never ad- 
minister active cathartics after the first week of the disease. 
There is no specific for typhoid fever, but the rational method 
of treatment is based on the principle of intestinal antisepsis. 
To this end, sulphocarbolate of zinc, given in one to five grain 
doses every three or four hours, through the whole course of 
the disease, lessens fever, delirium, diarrhoea, and changes the 
character of intestinal and nervous symptoms. Given in 
three to five grain doses in the prodromal stage it has checked 
many cases that might idtimately have terminated in typhoid 
fever. Sixty grains of the drug daily will cause no toxic 
symptoms. 

Salol, gr. v, every four hours ; beta-naphthol, gr. j-v, every 
four hours, and salicylic acid are advocated as intestinal anti- 
septics. Hydrochloric acid dilute, gtt. x-xx, every three hours, 
is astringent, antiseptic, and is used during the whole course. 
Bichloride of mercury is not reliable as an intestinal antisep- 
tic, for it is converted into the inert albuminate of mercury 
in the stomach. Tincture of iodine and carbolic acid are of 
service. Many other remedies have been used, but the above 
list will suffice as a reliable working-outline from a medicinal 
standpoint. 

Special Symptoms. — Fever is a symptom only, and not the 
disease ; it is nature's method of resisting disease. As long 
as temperature is below 103° F., little damage will occur. 
Quinine, acetanilide, phenacetin, and other drugs, in antipy- 
retic doses, are too irritating and depressing. Give a sponge- 
bath with cold water and alcohol, every two to six hours, to 



FEVERS. 43 

remove secretions from the skin and rednce temperature. In 
hyperpyrexia, or high fever, use cold baths (p. 23) to reduce 
temperature, rather than antipyretic drugs. Intestinal hemor- 
rhage, collapse, or pulmonary congestion contra-indicate cold 
baths. 

Diarrhoea. — Usually controlled by the sulphocarbolate of 
zinc or salol. If profuse, administer bismuth salicylate or 
other astringents, exercising care not to stop secretions and 
excretions entirely, for these products act harmfully if re- 
tained in the intestines. 

Hemorrhage. — Acetate of lead, zinc salts, tannic acid, and 
oil of turpentine are most commonly employed. Oil of tur- 
pentine (five to ten drops in an emulsion every three or four 
hours) is indicated in extreme tympany, tenderness, or actual 
hemorrhage. 

Headache, a common symptom, is lessened by applications 
of ice or the administration of the bromides, acetanilide, 
phenacetin, or pill acetanilide comp. (form, p. 27). 

Convalescence is slow. Avoid solid food and active cathartics 
for several weeks. Perforation has taken place more than 
one month following convalescence — one case is recorded at 
three months. Stimulants, best nutritious diet, freedom from 
all business care, and an out-door life for six months or a 
year. 

Observation. — Typhoid fever will run its course in spite of 
all medicinal remedies (so-called specifics), and best results 
are to be obtained from efficient nursing, proper attention to 
diet and hygiene, and the avoidance of the system of dosing 
with medicines. 



44 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

PERIODICAL FEVERS. 

YELLOW FEVER. 

Synonyms. — " Yellow Jack " j typhus icterodes ; malignant 
bilious fever ; sailor's fever ; Mediterranean fever. 

Definition. — An acute, contagious, malignant, epidemic or 
endemic, paroxysmal fever, occurring in warm climates, and 
recognized by sudden onset with high fever, a remission, fol- 
lowed by deep jaundice, black vomit, and collapse. 

Etiology. — Caused by a specific germ, as yet not discovered, 
which flourishes best at a temperature above 72° F., and is 
rendered inert by frost or heat of 225° F. Primarily it is a 
disease of tropical climates, usually along the coast, but fre- 
quently invades temperate climates of high altitude. In South 
America, the West Indies, and along the shores of the Mediter- 
ranean it is endemic, not spreading rapidly among the natives, 
but attacking strangers who are not acclimated. It is dis- 
tinctly non-malarial in character. Self -protective. Very con- 
tagious from infected clothing, merchandise, and the body of 
the sick. Period of incubation varies from six to ten days. 

Symptoms — First Stage. — Prodromes of headache, general 
malaise, uneasiness, anorexia, and feverish tendency. Onset is 
sudden, with a severe chill (occasionally prolonged), followed 
by high fever, 102° to 105° F. 5 dry, hot skin ; quick, tense 
pulse ; eyes unusually bright and liquid j severe pains in fore- 
head, back, legs, and epigastric region • general muscular 
soreness ; no delirium or loss of consciousness except in very 
severe cases ; bowels constipated ; tongue coated, moist, and 
flabby. A peculiar odor exists with these cases. Urine con- 
tains albumin. In thirty-six to forty-eight hours fever remits, 
and the disease assumes a different phase. 

Second Stage. — Temperature varies from 97° to 101° F, ; all 



FEVERS. 45 

symptoms subside ; stomach is irritable ; conjunctivae assume 
a yellow hue and the skin is tinged with yellow. Patient feels 
well and desires to be up. Bowels move freely, and passages 
are dark and biliary. Convalescence may begin here, and 
patient recover in one or two weeks. On the other hand, 
about one to four days following the remission, he passes into 
the last stage. 

Third Stage — Collapse. — All symptoms return ; pulse falls, 
is irregular and compressible ; skin is dry, cold, and deep 
yellow or bronzed, with livid spots here and there • hemor- 
rhages from the nose, ears, lungs, stomach, and internal or- 
gans are quite characteristic. Vomiting is frequent, and is 
black and grumous — black vomit. Urine is dark, albumi- 
nous, and often suppressed; consciousness is retained until 
death. Convalescence is very slow and tedious. 

Pathology. — The pathogenic germ has never been isolated, 
nor is it known how or where it is most active. Many symp- 
toms seem to point to the gastro-intestinal canal as its habitat. 
Post-mortem examination shows that the heart has under- 
gone granular degeneration ; fatty degeneration of the liver ; 
stomach and intestines congested and ecchymosed, and mu- 
cous membrane soft and friable. Kidneys are soft, granular, 
and show a condition of tubular nephritis ; hemorrhages into 
various serous cavities. 

Diagnosis. — Yellow fever is recognized by being epidemic 
or endemic; sudden onset, high fever, black vomit, albumi- 
nuria, one remission, deep jaundice, and running its course in 
a few hours or one week at most. 

Prognosis. — A very fatal disease. Mortality varies from 
ten to fifty percent, in different epidemics. 

Treatment. — Follow prophylactic measures strictly as in- 
dicated on page 21. Patient must be put in bed at once and 
entirely isolated. If possible, administer a full dose of calo- 



46 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

mel, gr. x, and socla bicarbonate, gr. x, and follow at once with 
snlphocarbolate of zinc, gr. v, every three honrs, or salol, gr. v, 
every four hours. Use cold baths for hyperpyrexia. Drink 
freely of alkaline, carbonated waters. Ice should be taken 
freely. Carbolic acid, gr. }, every two hours, is recommended. 
Cleanse lower bowel frequently with injections of cold water 
and snlphocarbolate of zinc (one dram to the half -pint). Avoid 
depressants, and stimulate from first. 

Diet. — Let it be liquid, consisting of beef-extracts, milk, 
and lime-water, or prepared infant food, given at regular in- 
tervals of three or four hours in small quantities. 



MALARIAL FEVERS. 

Malaria (Italian for "bad air") is a term applied to a group 
of fevers or toxaemia which are endemic in tropical and tem- 
perate regions, and produced by a miasmatic poison or bacil- 
lus called the bacillus malarke, isolated by Lemaire, Klebs, and 
others. Malarial poison develops in low, marshy flats, mead- 
ows, swamps, and damp forests where a large amount of 
decomposing vegetable matter is exposed for a long period 
to the heat of the sun; is most active during the hot, dry 
months of summer, in tropical climates, between the hours of 
sunset and sunrise, and rises with the fog several feet from 
the ground ; hence is capable of dissemination by currents of 
air. Malaria also exists in high elevations where temperature 
and conditions of the soil are favorable. Malarial poison 
usually enters the system through the respiratory tract, but 
may be taken in drinking-water and vegetable food. People 
who have not lived in malarial districts are very susceptible, 
and contract it readily. Colored people seem to possess a 
peculiar immunity, but may have it. One attack predisposes 



FEVERS. 47 

to another, and the disease may become active in the system 
many weeks after exposure, when the patient has moved to a 
non -malarious district. 

Period of incubation is very uncertain, and varies from a 
few days to two or three weeks. 

Malarial Types. — (I.) Intermittent fever; (II.) remittent 
fever; (III.) pernicious malarial fever; (IV.) chronic malaria. 

I. Intermittent Fever. 

Synonyms. — Ague ; chills and fever ; mild malarial fever ; 
paludal fever. 

Definition. — An acute, infectious, paroxysmal malarial fe- 
ver, recognized by a distinct chill, lasting about one hour, 
followed by" a period of great heat, and declining by profuse 
sweating, leaving the patient without fever and in an appar- 
ent state of health for an uncertain period of time, only to 
return again. 

Symptoms. — There may be slight headache, general indis- 
position, anorexia, nausea, and uneasiness preceding the onset. 

Onset or cold stage begins suddenly with a decided and pro- 
longed chill ; skin is rough, pale, and cold (cutis anserina) ; 
nails and lips are blue ; teeth chattering ; great thirst ; intense 
headache ; vomiting ; urine pale and copious ; pulse small 
and tense ; temperature is 101° to 105° F. This continues 
for about one hour, and is followed by a hot stage. 

Hot Stage. — Chill gradually ceases, and patient begins to 
feel hot and flushed ; skin assumes a dry, burning feeling ; 
pulse is full and rapid ; temperature varies from 103° to 107° 
F. ; urine is scanty and feverish ; face puff ed ; headache in- 
tense ; spleen enlarged. This stage varies in duration from 
three to four hours or longer. 

Sweating Stage. — The dry, hot condition of the skin gives 



48 ' A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

way to profuse sweating, which continues for several hours 
and soaks all the bed-clothing ; tongue is moist ; temperature 
falls gradually to normal, and all symptoms disappear, leav- 
ing the patient weak and nervous for a short time, when 
there is a distinct intermission, during which he enjoys appar- 
ent health. 

Varieties. — Quotidian ague has a distinct paroxysm every 
day ; tertian ague, every other day, and is the most common 
form; quartan ague, every fourth day; double quotidian ague, 
two attacks daily; double tertian ague, one paroxysm every 
day, the alternate ones being most severe. One type may 
change to another or assume a remittent form. Masked in- 
termittent or dumb ague does not have three stages; one stage 
may be replaced by facial neuralgia, or, in fact, no other 
symptom may exist except periodical neuralgia dependent on 
malarial poison. 

II. Remittent Fever. 

Synonyms. — Bilious remittent fever ; marsh fever. 

Definition. — A paroxysmal malarial fever of hot climates, 
recognized by a high rise of temperature, with active symp- 
toms, followed by a short remission, in which temperature 
never falls to normal, and a return of all symptoms in a few 
hours. 

Symptoms. — Onset is sudden, with a slight chill, headache, 
restlessness, aching pains in the arms and legs, thirst, nausea 
and vomiting, high fever, 102° to 107° F. ; pulse full, tense, 
and rapid ; constipation ; delirium ; conjunctivae congested ; 
epigastric oppression or soreness. 

Remission in six to eighteen hours after onset, when sweat- 
ing begins and all symptoms lessen. Headache, nausea, and 
general pains cease, and temperature falls to 99° or 100° F. 



FEVERS. 49 

(but never reaches normal during a remission), when patient 
sleeps calmly. In a few hours fever and all symptoms return 
with renewed vigor, but without an initial chill. Spleen is 
swollen and tender. Disease usually runs its course in one to 
three weeks, is quotidian in type, and may assume a typhoid 
form. Occasionally these cases run into chronic malaria, 
leaving such nervous symptoms as severe headache or local 
palsies. Jaundice often occurs, and may be mild or quite 
severe. 

III. Pernicious Malarial Fever. 

Synonyms. — Pernicious fever ; malignant, intermittent or 
remittent, fever 5 congestive fever. 

Description. — A malignant malarial fever, pursuing the 
same course as intermittent or remittent fever of the tertian 
or quotidian type, with the addition of intense congestion or 
hemorrhage from one or more internal organs, and general 
aggravation of all symptoms. Symptoms vary according to 
the organs affected. Fatality is mobt liable to follow second 
or third attacks. 

Cerebral Variety. — Intense congestion of the brain, effusion 
of serum into the ventricles, or cerebral apoplexy. There is 
delirium, stupor, or coma; pulse is slow and full; skin is 
either dusky or quite flushed ; delirium may be very violent 
and maniacal. Death is due to coma, meningitis, or compli- 
cations. 

Gastroenteric Variety. — Nausea, vomiting, bloody diarrhoea, 
anorexia, and intense thirst. Abdomen is not tender, but 
there is a sense of fullness or oppression in the epigastric 
region ; skin is cold and clammy. Symptoms may remit or 
intermit, and death ultimately ensue from exhaustion. Parox- 
ysms last about six hours. 



50 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Thoracic or Pulmonary Form. — Great dyspnoea ; congestion 
of the kings, with all attending symptoms ; weak pnlse ; skin 
is dnsky and cold. Most fatal form. 

Algid Form. — Cold stage appears to be prolonged, even 
though the temperature is high, until pulse decreases and is 
finally lost ; body becomes cold ; temperature falls to 85° or 
95° F. 5 voice is very faint ; expressionless face ; absolute 
clearness of the mind until death ; great thirst. May have 
vomiting and serous discharges from the bowels. 

Hemorrhagic Form. — It is closely allied to the congestive, and 
occurs in those who are subject to malarial attacks. Begins 
with a prolonged chill, epigastric distress, nausea and vomit- 
ing, headache, uneasiness, and deep jaundice. High fever soon 
follows ; great thirst ; pains over region of liver, stomach, and 
kidneys ; urine is smoky, and contains red blood-corpuscles. 
Epistaxis and intestinal hemorrhages, with signs of cerebral 
congestion. Uraemia ma}^ develop. During remission or 
intermission, all symptoms lessen or disappear. Liver and 
spleen are enlarged. Convalescence is very slow. Usually of 
the quotidian type. 

IV. Chronic Malaria. 

Description. — Persons who have been exposed to the mala- 
rial miasma for several years gradually become accustomed 
to its influences, and are not often seized with acute attacks. 
Such persons complain of general malaise, indigestion, ane- 
mia, high-colored urine, insomnia, headache, dizziness, ringing 
sounds in the ears, no fever, sore, tired feelings in the muscles 
and bones. The skin becomes brown or bronzed. Morris 
says, " The skin looks like an old, dirty buckwheat-cake." 
Spleen is enlarged, hard, tender, and occupies a large portion 
of the abdominal cavity j this enlarged spleen is called ague- 



FEVERS. 51 

cake. Liver is often enlarged. In fact, the patient possesses 
a general cachectic appearance peculiar to malaria. 

General Pathology. — All forms of malarial fevers arise 
from the same cause, namely, a miasmatic poison or germ 
called the bacillus malarice. It is possible that this germ is 
most active in the lymphatic and circulatory systems, but its 
method of action, reproduction, and growth still remains in 
obscurity. Why the disease assumes a quotidian type in one 
person and a tertian in another is not known. Direct trans- 
fusion of blood from malarial to healthy patients during the 
active stage of the disease will reproduce the disease in the 
latter, although it cannot be transmitted by any other means 
from the sick. The cold stage is caused by a temporary con- 
traction of the superficial arterioles of the skin, causing poor 
circulation. Hot stage is produced by a relaxation of the cap- 
illary vessels and an unusual engorgement of the superficial 
vessels. Profuse sweating depends upon a lack of vaso-motor 
power and temporary loss of inhibition of the sudoriferous 
glands. Post-mortem examination shows an enlarged, hard 
spleen with thickened capsule and trabeculae [ague-cake) ; 
slight enlargement of the liver; blood contains pigmentary 
masses which adhere to the blood-corpuscles (melanamiia), 
most marked in remittent and pernicious fever; hyperaemia 
of the brain and other organs; general discoloration of the 
skin, spleen, and liver, from pigmentary deposits from the 
blood. 

Diagnosis. — Pyamiia is distinguished by peculiar hectic 
fever, irregularity of chills, causation and formation of ab- 
scesses. Intermittent fever has normal temperature during the 
intermission, while the temperature and symptoms of remittent 
fever never become normal during the course of the disease. 

Yellow fever is epidemic ; short in duration ; has one parox- 
ysm only; black vomit; clean or slightly coated tongue; 



52 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

peculiar expression of the eyes ; delirium is mild or absent ; 
albuminuria • is self-protective ; does not respond readily to 
treatment. 

Prognosis. — Intermittent fever terminates in recovery or 
chronic malaria. Remittent fever affords a favorable prog- 
nosis. Pernicious fever is fatal in a large percentage of cases 
in a few hours to four days — death usually ensuing in the 
second or fourth paroxysm. Chronic malaria is amenable to 
treatment, but relapses very easily. 

Treatment. — Prophylaxis. — Avoid malarious districts ; or, 
if compelled to live in them, do not go out of the house dur- 
ing the night and early morning hours until the sun has 
cleared away fogs, for these afford an easy method of infec- 
tion. Do not drink water that is at all doubtful unless it 
has been previously sterilized. Keep the bowels active, and 
observe regular habits of diet, work, and rest. Avoid all 
unwholesome food. Thorough drainage and cultivation of 
marshy districts have done much toward eradicating malaria. 
Eucalyptus trees are said to absorb and destroy malarial poi- 
son, but modern research tends to disprove this, as their only 
virtue lies in absorbing moisture and breaking currents of 
wind which might disseminate the poison. Shrubbery and 
foliage of any kind will have the same action. 

Diet. — Vary diet according to symptoms, but it should gen- 
erally consist of liquid and farinaceous foods — beef broths 
and extracts, chicken-broth, baked potatoes, soft-boiled rice, 
milk, junket, tapioca, corn-starch, sago, boiled fish in mode- 
ration, soft-boiled egg. 

Medicinal Treatment. — During the Paroxysm. — If called 
immediately before or daring the chill, administer a hypoder- 
mic injection of morphina sulph., gr. }, and atrophia sulph., 
gr. t!o> which will abort or greatly mitigate a chill; put 
patient in bed ; cover him with blankets, and use hot- water 



FEVERS. 53 

bottles. A full dose of spts. chloroformi, f 3j, or pilocarpine, 
gr. --re to i, hypodermically, will often answer. 

Hot Stage. — Greatest relief is afforded by a cold sponge- 
bath, cold, acid drinks, or a regular cold bath. Antipyretic 
drugs are too slow in action. 

Sweating Stage. — Cold sponge-baths with cold water and 
alcohol, or some mild astringent ; cold, acid drinks. Atropine, 
hypodermically, if sweating is profuse. Curative agents are 
useless during a paroxysm of intermittent fever. 

Intermission or Remission. — Induce active catharsis with 
calomel and salines. Cinchona and its preparations are the 
accepted remedies, and in order to prove efficacious must be 
pushed until the full physiological effect is produced, and that 
at least two hours preceding the anticipated attack. Quinine 
bisulphate or sulphate, administered by the stomach or per 
rectum, in doses varying from five to forty grains, beginning 
four to six hours before the anticipated paroxysm, and con- 
tinued every one or three hours until its full effects are pro- 
duced. When a paroxysm is aborted, give small doses of 
quinine until next day, when it must be increased as before 
at the time for the paroxysm. Continue this method every 
two, four, or six days until the twenty-first day is passed, 
when it is not likely to return unless patient is still exposed 
to the poison. 

Irritability of the stomach is lessened by calomel, gr. x^-, 
every hour ; arsenite of copper, gr. -^j-q, every fifteen minutes 
to half an hour, in solution ; small doses of morphina or 
cocaine. 

Hyperpyrexia requires cold baths and not antipyretic drugs. 

Headache is relieved by pill acetanilide comp. (form, p. 27), 
every half -hour. 

Congestive and hemorrhagic symptoms require symptomatic 
treatment as given in other parts of this work. 



54 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Convalescence. — Give tonics of iron, quinine, strychnine, 
arsenic, and cod-liver oil, with, good, nourishing diet. 

Chronic Malaria. — Change residence to a non-malarious dis- 
trict ; keep bowels active every day with cathartics. Quinine 
is not of much benefit. Arsenic is the best remedy, and 
should be pushed to the point of tolerance and used for long 
periods of time. Salts of mercury and iodides are sometimes 
given with advantage. 

Enlarged spleen (ague-cake) is reduced by inunctions of red 
iodide of mercury and lard, baked in before a hot fire ; cold 
douches over the spleen are beneficial; galvanism is some- 
times used. 

[Note. — Many remedies are recommended in malarial dis- 
eases, but none yet mentioned will take the place of quinine, 
which may be termed almost a specific if properly adminis- 
tered. Malaria can never be wholly eradicated from the sys- 
tem as long as patients live in malarial districts.] 



ERUPTIVE FEVERS. 

VARICELLA. 

Synonym . — Chicken-pox. 

Definition. — A specific, infectious, eruptive disease, mani- 
festing itself by slight febrile reaction and successive crops of 
smooth vesicles on all parts of the body, at the end of twenty- 
four hours, which desiccate rapidly and leave a small scab. 

Etiology. — Due to a specific germ, that is communicated 
by direct contact. Often epidemic. A disease of childhood. 

Symptoms. — Slight malaise ; low fever ; pulse slightly in- 
creased ; loss of appetite ; thirst ; constipation. Disease may 
begin with a rigor, chill, chilly sensations, or a convulsion, 
followed by a temperature of 103° F. The eruption, pri- 



FEVERS. 55 

marily, is erythematous, and changes in a few hours to a soft 
papule. At the end of the first twenty-four hours, distinct 
vesicles, filled with a clear or white serous fluid, appear. 
When punctured these vesicles collapse. It may come in 
crops, during several days, on the face, trunk, and extremities. 
Vesicles sometimes form in the mouth and throat. In three 
or five days these vesicles rupture spontaneously, and small 
scabs form and fall off in six to ten days. A few isolated 
vesicles may become pustular, but this is most common in 
cases where there is uncleanliness. Cicatrices are not the 
rule, but may follow severe cases. A mild attack may be 
overlooked by careless parents. 

Diagnosis. — May be confounded with variola during onset 
or vesicular stage, but the mild constitutional symptoms, 
time of eruption, complete collapse of vesicles when punct- 
ured, absence of general pustules, and secondary fever serve 
to characterize varicella. 

Prognosis. — Death is extremely rare, and is caused by com- 
plications. 

Treatment. — It is wise to put the child in bed and isolate 
him until the disease is past, even though the case is very 
mild. Administer a mild cathartic, and follow with some 
mild fever mixture, such as aconite, liquor ammonii acetatis, 
and simple syrup. Light diet. Watch for complications. If 
pitting is feared, treat locally as in variola (p. 60). 

VARIOLA. 

Synonym .—Smallpox. 

Definition. — An acute, epidemic, specific, eruptive, conta- 
gious fever, recognized by the sudden onset of fever and the 
appearance of a papular rash over all parts of the body on 
the third day, which becomes vesicular, then pustular, and 



56 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

finally forms a scab that falls off about the twenty-first day, 
leaving a pitted cicatrix and always accompanied by second- 
ary fever during the stage of pustulation. 

Varieties. — Discrete variola ; confluent variola ; malignant 
variola ; mitigated variola, or varioloid. 

Etiology. — The exciting cause of the disease is undoubtedly 
a germ, as yet not isolated. Contagion, directly or indirectly, 
is its only means of origin, for the disease never arises de 
novo. Debilitated and unvaccinated persons are most sus- 
ceptible to it. One attack usually prevents another. Negroes 
have a peculiar susceptibility to variola. Incubation is twelve 
to fourteen days. 

Symptoms. — Discrete Variola. — Onset is sudden, with a 
chill or rigor; great pain in the lumbar region, head, arms, 
and legs ; nausea ; and fever varying from 102° to 105° F. 
Tongue is coated; anorexia; constipation; occasional delir- 
ium ; and full, tense, rapid pulse. 

Eruption. — On the third day, following onset, erythematous 
spots appear, first on the forehead, face, and neck, and, later, 
on all parts of the body. On the fifth day these spots become 
papules, which feel like shot under the skin. At this period 
the fever and acute symptoms lessen, or, in some cases, sub- 
side entirely. On the sixth day the papules become vesicles 
which are depressed in the center (umbilicated) and do not 
collapse when punctured. About the eighth day the vesicles 
become pustular, and are soon surrounded with a band of 
dark-red, swollen skin. On the eleventh or twelfth day pus 
begins to exude from the pustules, and soon forms a hard, in- 
spissated mass or scab which does not fall until the eighteenth 
or twenty-first day. A red, depressed or pitted cicatrix re- 
mains for several weeks or months, and ultimately becomes 
white. 

Secondary fever of a severe type and general aggravation 



FEVERS. 57 

of all symptoms begin on the eighth day, when the eruption 
becomes pustular, and continue three to five days. There is 
a peculiar, indescribable odor present in all cases of variola, 
most marked during the stage of pustulation. 

Confluent Variola is a more severe form, and is character- 
ized by an aggravation of all symptoms, but more especially 
the eruption, which is so abundant that the vesicles and pus- 
tules coalesce in many places, causing intense swelling, pain, 
fever, and large cicatrices. Mucous membranes are more 
liable to become involved and complications are greater. 
Eruption may appear a few hours earlier than in discrete 
variola. 

Malignant Variola, black smallpox, or hemorrhagic variola 
is recognized by a sudden onset with hyperpyrexia, delirium, 
convulsions, and slight or very severe and fatal hemorrhages 
from the mucous membrane of the stomach, nose, lungs, 
kidneys, or uterus. Eruption appears within twenty-four or 
forty-eight hours ; is very thick and dark in color ; whole 
body is covered with petechia?. Recovery from malignant 
variola is rare. 

Mitigated Variola, or Varioloid, is a mild disease occurring 
in those persons who have been protected by previous vacci- 
nation or second attacks of variola. All symptoms are mild ; 
eruption is scattered and does not generally become pustular j 
hence secondary fever is rare. 

Complications and sequelce are pneumonia, ptyalism, pleu- 
risy, erysipelas, purulent conjunctivitis, keratitis, otitis media, 
obstinate diarrhoea, pyasmia, abscesses, caries, and paralysis 
of the bladder, larynx, or extremities. 

Pathology. — The exact pathological process of variola is 
not understood. It is undoubtedly due to a specific germ, 
which is most active in the vesicles, pustules, and scabs 
formed, The characteristic lesions of variola begin in the 



58 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

papillary layer of the skin, and are frequently situated over 
a hair follicle or glands, which may account in part for um- 
bilication of the vesicles. Each vesicle is subdivided into 
small compartments (loculated) by bands of fiber, and will not 
collapse when punctured. Fatty degeneration of the liver, 
heart, and kidneys is found post-mortem. 

Diagnosis — Measles, acute syphilis, and varicella may be 
mistaken for variola in the onset, but the characteristic symp- 
toms of the latter, already described, and the presence of an 
epidemic will serve to differentiate. 

Prognosis. — Discrete variola usually terminates in recovery. 
Confluent variola is fatal in nearly fifty percent, of the cases. 
Malignant variola is almost invariably fatal. Varioloid rarely 
causes death, and is short in duration. Unfavorable signs 
are hyperpyrexia, wild delirium, high secondary fever, multi- 
ple abscesses, pneumonia, or any grave complication. 

Treatment. — Prophylaxis. — Isolation must be enforced, and 
the most stringent restrictions adopted to prevent spread of 
the disease (see p. 21). Vaccination is probably the safest 
prophylactic measure. 

Vaccination consists in inoculating the body with virus 
taken from the vesicle of a cow suffering with cowpox, or 
from the scab or virus taken from the vesicle of a healthy 
person who has been vaccinated. The best method of inocu- 
lation consists in scraping away the upper layer of the skin 
on the arm or leg, rubbing in the moistened virus, and allow- 
ing it to dry. If it is successfully inoculated it begins to 
grow red, and, on the third day, a small vesicle forms at the 
point of inoculation, which becomes umbilicated or depressed 
on the sixth day. About this time there is some fever, rest- 
lessness, anorexia, and a general sick feeling in most cases. 
About the eighth day the vesicle becomes a pustule, sur- 
rounded with a distinct, pink or red areola ; the arm some- 



FEVERS. 59 

times swells to enormous size, and is very painful. From the 
tenth to the twelfth day the pustule begins to dry, and by 
the fourteenth day a hard, brown scab is formed, which falls 
off on the twenty-first or twenty-third day, leaving a distinct 
cicatrix which persists for life. Vaccination is often accom- 
panied or followed by a papular eruption, which will soon 
disappear and need cause no alarm. Persons who are vacci- 
nated are afforded immunity from true smallpox, and when 
it is contracted it is usually varioloid and rarely fatal. This 
is not an absolute preventive, for true variola may occur in 
those who have been vaccinated previously. 

The patient shoidd be kept in bed in a dark, well- ventilated 
room. No known remedy seems to shorten or mitigate the 
course of variola. Begin treatment by the administration of 
a free calomel purge. Full doses of salicylate of soda, gr. 
v-xv, every two hours, will relieve pains and fever during the 
onset. Hypodermics of morphina must be given in extreme 
pain. Salol, gr. ij-v, or sulphocarbolate of zinc, gr. j-v, every 
four hours, is frequently given during the whole course of 
the disease with benefit. 

Insomnia is met by full doses of chloral or the bromides. 

Hyperpyrexia requires the cold bath, to be followed by a 
mild fever mixture, pill acetanilide comp. (form, p. 27), or 
any other desirable antipyretic. Three or four sponge-baths 
should be given during the clay, with a cold antiseptic solu- 
tion of acid bichloride of mercury. Watch the heart, and 
begin to stimulate freely whenever it shows signs of weak- 
ness. Tonics of iron, quinine, strychnine, and arsenic. Full 
doses of cocaine are said to prevent the violent form of erup- 
tion, confluence, and pitting : this is questionable. 

Diet should be bland, nutritious, and liquid, and must be 
given at intervals of three or four hours. Milk, bovinine, 
scraped beef, soft-boiled egg, animal-broths, oyster-broths,, 



60 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

and beef-exteacts. Water should be given in small amounts 
at frequent intervals ; cracked ice is permissible ad libitum. 

Sore throat requires astringent, antiseptic washes and gar- 
gles. Peroxide of hydrogen, glycerine, and water. 

Diarrhoea is usually controlled by salol or sulphocarbolate 
of zinc, but may require more astringent medication. 

Open large abscesses, and treat antiseptically without poul- 
tices. To avoid disfigurement and jutting, the room must be 
kept dark and the exposed parts covered with some antiseptic 
unguent, powder, or wash. My own preference is given to 
the constant application of a cold antiseptic solution of acid 
bichloride of mercury, one to five or ten thousand, or peroxide 
of hydrogen, one to four, exercising care to keep the parts 
thoroughly cleansed and the cotton dressing changed fre- 
quently. Collodion, carbolic acid, ung. zinci oxidi, and boric 
acid are recommended as local applications to prevent pitting. 

SCARLATINA. 

Synonym. — Scralet fever. 

Definition. — An acute, specific, contagious, self-limited, 
self-protective disease of childhood, manifesting itself by a 
sudden onset with a chill, rigors, convulsions, or vomiting, 
followed by high fever, sore throat, and the appearance of a 
bright-scarlet, uniform rash over the whole body, at the end 
of the first twenty-four or thirty hours, gradual defervescence, 
and desquamation of the epithelial layer of the skin at the 
end of the seventh or tenth day. 

Varieties. — Scarlatina simplex ; scarlatina anginosa ; scar- 
latina maligna. 

Etiology. — Due to a very active, specific germ, not yet iso- 
lated. It is the most contagious of children's diseases, and 
can be carried to any distance by books, letters, clothing, and 



FEVERS. 61 

careless persons. One epidemic in England was caused by 
milk from one cow where the disease existed. The vitality 
of the germ is not lessened by age, for cases originate from 
toys, books, and clothing that have been used by infected 
persons years before. Most common among children. Very 
young infants and adults are not so susceptible ; women who 
have recently been confined show a peculiar susceptibility to 
it. Period of incubation is about one week. 

Symptoms. — Scarlatina simplex. — Patient may be peev- 
ish, cross, restless, and complains of slight sore throat and 
headache for a few days before the onset. Invasion is sudden, 
with a chill or rigor, intense headache, nausea or vomiting • a 
temperature of 103° to 105° F. ; rapid pulse and quickened 
respiration; skin is dry and hot. Throat is sore, dry, and 
red ; tongue is coated, red at the tip and edges, and papillae 
prominent. 

In twenty-four or thirty hours after the onset a scarlet 
eruption appears on the face and neck, and spreads rapidly 
in a few hours to the whole body. This eruption consists of 
minute points, with a distinct areola around each point, 
which coalesce and form a uniform redness with no interven- 
ing healthy skin. Parts of the body may be entirely free 
from the eruption. On the fourth day following the onset 
the rash begins to fade, and on the seventh or tenth day des- 
quamation begins. The skin is first scaly or rough in appear- 
ance, and soon large flakes or pieces of epidermis can be 
peeled off — especially so on the hands and feet. Desquama- 
tion continues until the fifth or sixth week after onset. 

Soreness of the throat and tongue is most severe after the 
third day; tongue presents a strawberry appearance, and is 
often fissured and dry • lips crack, and are covered with a 
thick, hardened sordes and epithelium ; temperature remains 
high, 103° to 107° F., for three days ; delirium is a common 



62 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

symptom. Diarrhoea may supervene. As the rash fades, the 
temperature and all symptoms subside by lysis. 

Scarlatina anginosa pursues the same course as the sim- 
ple form, except that the throat symptoms are greatly aggra- 
vated. Throat is very sore, ulcerated in patches, and covered 
with a thick, offensive, tenacious, yellow or white exudation. 
Cervical glands and tonsils are swollen, and abscesses often 
form in them. Deglutition and breathing are quite difficult. 
Inflammation not infrequently spreads to the middle ear, 
producing a suppurative otitis media with permanent loss of 
hearing. The Schneiderian mucous membrane, conjunctivae, 
and cornea are often involved through extension of the in- 
flammation by continuity of structure. 

Scarlatina maligna is a fatal form of the disease. Onset 
is violent and sudden, with convulsions, great prostration, a 
purple, petechial eruption, hyperpyrexia, and death in one to 
four days. 

Complications. — Acute tubular nephritis is the most com- 
mon complication, and may occur at any stage of the dis- 
ease. Urine is smoky; contains albumin, red blood-cells, 
and tube-casts. It is liable to assume a chronic form with 
dropsy. 

Latent tuberculosis is often brought into activity by an at- 
tack of scarlatina. 

Endocarditis and rheumatism often accompany or follow 
scarlatina. 

Diagnosis. — Must be distinguished from morbilli, rotheln, 
and variola. Typical cases are so distinctive that mistakes 
in diagnosis are inexcusable. Care must be taken not to 
confound scarlatina anginosa with time diphtheria, 

Prognosis. — A positive prognosis is impossible, as mild 
cases often assume the worst forms. Mild, uncomplicated 
cases usually recover promptly. Always caution parents of 



FEVERS. 63 

possible sequelae and complications. Puerperal cases are 
mostly fatal. 

Treatment. — Isolation and prophylactic treatment as given 
on page 21. It is questionable whether any known remedy 
will limit the course of scarlatina. Objectionable symptoms 
and complications can be greatly mitigated. Begin treatment 
with a good cathartic. Triturates of calomel, gr. ^ every 
half-hour, will relieve nausea and vomiting and produce 
cathartic action. Follow this with : 

Infus. digitalis f 5 iij. 

Liq. ammonii acetatis f 1 ss. 

Syr. aurantii floratis q. s. ad. f ? iv. 

M. Signa. One teaspoonful every three hours. 

Digitalis must be pushed to its full extent to produce good 
results. It is diuretic, a heart-tonic, lessens fever, and aids 
in preventing complications. In addition to this, give the 
following to reduce fever and favor the appearance of the 
eruption : 

Tr. aconiti radicis. 

Tr. belladonnae aa. gtt. xxx. 

Tr. rhois toxicodendron gtt. x. 

Aquas q. s. ad. f I iv. 

M. Signa. One teaspoonful every hour until the rash has 
properly appeared, then every two or three hours. 

If the temperature remains above 103° F., give cold sponge- 
baths at intervals of two or four hours in preference to anti- 
pyretics. For the sore mouth and throat, use a wash of 
chlorate of potash and boric acid ; or a very desirable com- 
bination is : 



64 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Hydrogen peroxide. . (15-volnme sol.) f?ij. 
Sol. cocainae hydroeliloratis . . . .(4 %) gtt. x. 

Mel. despumati vel mel. rosae f I ss. 

Aquas q. s. ad. f J iv. 

M. Signa. Use freely as a mouth-wash, gargle, or spray. 
If too strong, dilute with pure water. 

When the tongue is dry and parched, apply borax and 
glycerin several times daily with a soft brush. For the dry 
condition of the lips apply tallow, 3 j, and spts. camphorae, 
gtt. x. Ice and carbonated waters for thirst. 

During exfoliation use some good antiseptic ointment or 
wash. Bathe several times daily with a good antiseptic wash. 
Follow, during convalescence, with tonics of iron and strych- 
nine. Meet complications as they arise. 

Diet should be light, nutritious, and unseasoned. Milk, 
butter-milk, vegetable and animal broths, rice, tapioca, sago, 
and small amounts of game and fish. Orange- juice may be 
used freely at all periods. 

MORBILLI. 

Synonym . — Measles. 

Definition. — An acute, contagious, self -protective, self -lim- 
ited, epidemic fever of childhood, recognized by sudden onset, 
marked catarrhal symptoms of the eyes and respiratory tract, 
and the appearance of a diffuse rash on the fourth day. 

Etiology. — A disease of childhood, but may occur in the 
adult. Young children are not very susceptible. Always 
caused by direct or indirect exposure to some previous case. 
The germs of morbilli are often carried by physicians, nurses, 
and visitors to other children. There seems to be no special 



FEVERS. 65 

predisposition on the part of delicate children. It is most 
contagious during the catarrhal stage and period of desqua- 
mation. Period of incubation is about ten days. 

Symptoms. — Child is restless, peevish, flushed in the face, 
nauseated, and has little appetite. A chill, rigor, convulsion, 
or chilly sensations herald the onset. Temperature is 102° 
to 104° F. ; eyes are red, swollen, and have a suffused, liquid 
appearance ; photophobia ; catarrh of the nasal mucous mem- 
brane, with profuse, watery and irritating discharge ; tongue is 
covered with a white fur ; pharynx is red and congested ; 
a very annoying, dry, hacking cough. Diarrhoea may occur. 
On the second or third day the temperature may fall to nor- 
mal, but rises suddenly at the end of the third day or the 
beginning of the fourth. 

Eruption, on the fourth day, appears on the forehead and 
neck, and gradually spreads to all parts of the body. It con- 
sists of slightly raised, crescentic, and irregular erythematous 
red spots, with healthy skin intervening. It begins to fade in 
three days, assuming a brown, a pale-yellow, and then a light 
color, and disappears from the face first. All symptoms begin 
to subside when the rash reaches its height, and by the ninth 
day disappear. Rash is followed by a desquamation of fine, bran- 
like scales, accompanied by mild or intense itching of the skin. 

Varieties. — Malignant, hemorrhagic, or black measles be- 
gins suddenly with great aggravation of all symptoms and 
hyperpyrexia. The rash becomes petechial, hemorrhagic, 
and of a dark-purple or black color. Haemoptysis is common. 
These cases are usually fatal. 

Morbilli sine catarrho vel sine eruptione — measles without 
catarrh or eruption — is very doubtful, although such cases 
are described. 

Complications and Sequela?. — Conjunctivitis ; ophthalmia ; 



66 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

otitis media ; chronic nasal catarrh ; chronic laryngitis ; acute 
catarrhal pneumonia ; tuberculosis ; noma ; parotitis j stoma- 
titis j hypertrophy of the tonsils ; and general debility. 

Pathology. — No distinct pathological process has been dis- 
covered, but the disease is undoubtedly dependent on a germ 
for its activity. 

Diagnosis. — No disease should be mistaken for morbilli 
after the characteristic eruption occurs on the fourth day. 
Scarlatina is ushered in by a very high fever, no catarrhal 
symptoms about the eyes and nose, and the appearance of a 
uniform scarlet rash at the end of twenty-four hours. 

Morbilli in the colored race is diagnosed by the catarrhal 
symptoms, time of the eruption, and the appearance of 
patches of irregular, crescentic form, not red, but of a coppery 
color, and much different from the natural black skin. 

Prognosis. — Uncomplicated cases recover promptly. Ma- 
lignant cases terminate fatally. Latent tuberculosis may be 
brought into activity by an attack. 

Treatment. — Specific medication is entirely out of the 
question, as nothing appears to limit its course. The main 
treatment lies in regulating hygiene and diet, preventing 
complications, and relieving objectionable symptoms. Keep 
the room dark to prevent eye-complications. The following 
combination relieves cough, lessens fever, and prevents tend- 
ency to congestions : 

Tr. aconiti radicis. 

Tr. rhois toxicodendron. 

Tr. belladonnse aa. gtt. viij. 

Morphinaa sulpha tis gr. j. 

Aquae q. s. ad. f 1 iv. 

M. Signa. One teaspoonful every two or three hours as 
needed. 



FEVERS. 67 

Bathe frequently with some cold or tepid antiseptic solu- 
tion. During desquamation, use an unguent or antiseptic 
wash to relieve itching and prevent spread of the scales. 

Malignant morbilli must be treated symptomatically, and 
free use made of cold baths and stimulants. In all cases 
keep up a free action of the bowels. Check diarrhoea with 
appropriate remedies. In marked nervous symptoms or convul- 
sions immerse the child's body to the neck in hot water, and 
apply ice to its head. Continue this for any length of time 
necessary to give relief. Best diet and tonics during conva- 
lescence. If the eyes are greatly affected, use an eye-wash of 
boric acid, gr. x, in water, 1 j, frequently. 

ROTHELN. 

Synonyms. — Rubeola ; roseola ; rubella ; false measles ; 
German measles; French measels. 

Definition. — An acute, contagious, epidemic, eruptive, self- 
limited f ever, recognized by sudden onset with a chill or slight 
catarrhal symptoms, and the appearance of an irregular dis- 
crete eruption, from the first to the third day, similar to 
morbilli. 

Etiology. — Is certainly caused by a distinct germ, not yet 
isolated. Contagious. Rotheln is not a hybrid variety of 
morbilli and scarlatina. Adults are frequently affected by it. 
Period of incubation is about ten days. 

Symptoms. — Prodromal symptoms are usually absent. 
Onset is marked by a rigor, chill, convulsion, or chilly sensa- 
tions, nausea and vomiting. Throat is slightly sore; eyes 
are red ; lachrymation is profuse ; coryza and sneezing. The 
cervical lymphatic glands are swollen and tender ; slight or 
severe cough; headache. Fever is very slight or entirely 
absent. 



68 A SYNOPSIS OP THE PRACTICE OP MEDICINE. 

Eruption appears on the first, second, or third day on the 
face, neck, and chest, gradually spreading to other parts of 
the body, and lasting about two or three days. Eruption is 
composed of numerous very small, rose-colored or pink, round 
or oval spots, distinctly isolated, and rarely coalescing to 
form crescentic patches. It is slightly elevated, very itchy, 
and, when it subsides, fine scales desquamate. The eruption 
may fade away and reappear again without harm. Compli- 
cations are not common, pneumonia and nephritis being the 
principal ones. 

Diagnosis. — Morbilli has severe catarrh, higher fever, ap- 
pearance of a crescentic rash on the fourth day, longer in 
duration, more severe sequela?, and extensive desquamation. 

Scarlatina has very high fever, absence of catarrhal symp- 
toms, a confluent scarlet rash, desquamation in large patches, 
severe sequelae, and great prostration. 

Prognosis. — Most cases recover in one week or ten days. 

Treatment. — Pursue the same general symptomatic treat- 
ment as in morbilli. 

DENGUE. 

Synonyms. — Break-bone fever ; dandy fever. 

Description. — It is a disease of tropical and hot climates, 
whose distinct cause is unknown. Some authors claim it to 
be of the malarial type, but this is very doubtful. It is an 
acute, infectious, epidemic disease, whose period of incubation 
varies from three to six days. Onset is sudden, with severe 
pains in one or more of the joints and back ; a severe, boring 
pain in the shafts of the long bones, shifting from one part of 
the body to another ; high fever ; headache ; nausea ; stiffness 
of the muscles ; and severe pains in the eyes. Sometimes a 
uniform red rash appears with the primary fever, and sub- 



FEVERS. 69 

sides in one or two days with the fever, by lysis or crisis, 
leaving the patient weak, anxions, or exhausted. In two or 
three days fever returns as before, and a diffuse red rash 
similar to scarlatina appears on the face, neck, and hands, and 
spreads to the whole body. It often resembles the eruption 
of urticaria, and is very itchy. Fever subsides, pains dis- 
appear about the eighth day, and desquamation of the skin 
ensues. Relapses are of frequent occurrence; some cases 
pursue a chronic course for months or years, leaving the 
joints deformed or anchylosed. It is rarely fatal except in 
very young or old people, or persons suffering with old 
chronic diseases. 

It is differentiated from acute rheumatism and scarlatina by 
its short duration, relapses, character of the eruption, and the 
epidemics. 

Treatment. — Stimulate the emunctories by a free purge, 
free diaphoresis, and diuresis. For the pains, give full doses 
of the salicylates, salol, acetanilide, phenacetin, or pill acet- 
anilide comp. (form, p. 27). Avoid opium unless absolutely 
necessary. Antiseptic, carbolated washes or unguents to the 
skin to relieve pruritis. Frequent cold baths ; good, stimulat- 
ing diet ; and, during convalescence, massage and inunctions 
of hot olive-oil or lard, two or three times daily, around the 
affected joints. 



ERYSIPELAS. 

Synonyms. — St. Anthony's fire ; the rose. 

Definition. — An acute, contagious, specific, eruptive fever, 
manifesting itself by sudden onset with a chill, high fever, 
and. local or diffuse inflammation of the skin and subcuta- 
neous tissue of the face or other parts of the body. 



70 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Etiology. — It is caused by the entrance of the Micrococcus 
erysipelatis into the blood or lymphatics through some abra- 
sion of the skin, be it a slight scratch or a severe surgical 
wound. Medical and surgical erysipelas are one and the same 
disease, due to the same cause ; the latter occurring after 
surgical operations, and is more extensive. It is contagious, 
and often becomes epidemic in surgical and obstetrical wards. 
Very young and old people are most susceptible to its influ- 
ence. Those who are debilitated by chronic or acute dis- 
eases, those subject to exposure to severe cold, bad hygiene 
and diet, are most susceptible. The face is most commonly 
affected. Period of incubation varies from three to seven 
days. 

Symptoms. — Onset. — There may be a feeling of uneasiness 
or general malaise for one or two days, followed by a rigor 
or chill, high fever, headache, nausea, anorexia, and, possibly, 
diarrhoea. A few hours later there is a stinging, burning, or 
itching sensation at one spot on the face, nose, or ear, at the 
point of inoculation. On examination this spot is red, swollen, 
and tender. A small vesicle or papule forms. Inflammation 
soon spreads to the whole face and scalp j skin is swollen, red, 
tense, hot, shiny, and covered with small vesicles. It is much 
darker red in the central area, and shades off in color to a dis- 
tinct line of demarcation between the affected and healthy 
skin. Pain, burning, itching, and throbbing are very severe 
at times ; glands of the neck are swollen ; throat is sore ; and 
general depression is marked. In five to seven days inflam- 
mation and severe symptoms begin to subside, and exfoliation 
of the epidermis ensues on the affected area. Small or large 
a,bscesses not infrequently form. Temporary albuminuria 
may be present. 

Phlegmonous Erysipelas is a more severe type of the sim- 
ple variety, and is accompanied by more severe constitutional 



FEVERS. 71 

symptoms, delirium, and coma. Multiple or single abscesses 
form in the cellular tissue, and the local manifestations are 
more severe, although confined to a limited area. Death is 
caused by general depression, exhaustion, pyaemia, oedema of 
larynx and pharynx, or meningitis. 

Pathology. — The primary lesion in every case is some abra- 
sion of the skin through which the Micrococcus erysipelatis 
gains entrance. The germ grows, reproduces itself, and forms 
ptomaines which act as a local irritant, causiug inflammation. 
As a result of the irritation and inflammation, small vesicles 
form j swelling results, together with redness and pain. The 
virus travels through the lymphatics to the subcellular tissues 
and lymphatic glands, where it is checked. Ptomaines are 
carried into the geueral circulation and produce constitutional 
symptoms. Abscesses are due to a mixed microbic infection — 
that is, the introduction of pyogenic germs in addition to the 
germs of erysipelas. 

Diagnosis. — Easily distinguished from all other affections 
by sudden onset, fever, local inflammation with a shiny, tense 
skin covered with small vesicles, a distinct line of demarka- 
tion, and possibility of contagion. 

Prognosis. — Simple erysipelas is rarely fatal. Phlegmonous 
erysipelas requires a guarded prognosis, and is very fatal. 
Puerperal erysipelas usually terminates in death. 

Treatment. — Local Measures. — The disease being due to a 
germ, local applications should be antiseptic and non-irritat- 
ing. Poultices should be avoided, as they favor suppuration. 
Make constant applications of acid bichloride of mercury (1 to 
3000) and never allow the parts to become dry. Peroxide of 
hydrogen acts admirably if applied constantly, either in its 
purity or diluted. A one-percent, solution of fuchsin, painted 
over the parts, forms a coating impervious to gases and liquids. 
Cures are reported from a few applications. Open vesicles as 



72 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

they form, and pursue most scrupulous cleanliness and anti- 
sepsis. Applications of iodine, solutions of iron, nitrate of 
silver, and others act as local antiseptics, but are objectionable 
on account of discoloration of the skin. If seen early, when it 
amounts to a mere point or very small area, multiple incisions 
around the outer zone of demarkation, made sufficiently deep 
to sever the lymphatic vessels leading from the part, and local 
antisepsis often cut it short. Open abscesses freely, and 
treat antiseptically without poultices. 

Constitutional Measures. — Administer a saline cathartic, 
and see that it acts freely. Establish diaphoresis with fluid 
extract of jaborandi, gtt. xx, every two to four hours, admin- 
istered with hot drinks. The jaborandi treatment is claimed 
to cut every case short if continued several days. Pilocarpine, 
gr. J, hypodermically. Tonics of iron and quinine, every four 
hours, aid materially in cimng the affection. Give most nutri- 
tious, stimulating diet, and insist on rest in bed. Antipyretic 
measures are unnecessary except in high fever, in which case 
use cold baths. Use every measure to prevent contagion, and 
do not attend cases of confinement at the same time you are 
treating erysipelas. 



GENERAL INFECTIOUS AND CONTAGIOUS 

DISEASES. 

CHOLERA. 

Synonyms. — Asiatic cholera 5 epidemic cholera; sporadic 
cholera. 

Definition. — An acute, specific, epidemic or endemic, infec- 
tious, malignant disease, recognized by sudden onset, profuse 
vomiting, severe cramps, rice-water stools, collapse, and death 
in a few hours or days. 

Etiology. — The direct cause of the disease seems to be the 
Spirillum cholerw or comma bacillus of Koch, which is an aerobic 
germ and is carried by drinking-water, milk, food, and the 
stools of the patient. Decaying vegetable matter, intense 
heat of a dry season, bad hygiene, over-crowding, summer 
complaints, and carelessness predispose to its development. 
Although hot weather favors its development, some of the 
worst epidemics have occurred in Russia in midwinter. The 
germs may be carried in rags, merchandise, and letters. It 
is not self -protective. Period of incubation varies from two to 
seven days. 

Symptoms. — Cholera is usually preceded for a few hours 
or days by a feeling of lassitude, uneasiness, slight headache, 
lack of appetite, occasional dizziness, slight diarrhoea, and 
weakness. There is a distinct chill or chilly sensations, accom- 
panied by epigastric and abdominal pain, nausea, coated 
tongue, bad taste in the mouth, and profuse diarrhcea. At 

73 



74 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

first the diarrhoea contains fecal matter, but it changes in 
quality to an opaque, copious, or colorless fluid which is 
passed every few minutes or seconds. These so-called rice- 
water stools are alkaline in reaction, have a specific gravity 
of about 1009, contain albumin, and deposit a fine mass of 
leucocytes, mucus, epithelium, shreds of tissue, salts, and 
bacteria. These passages are accompanied by gurgling and 
rumbling sounds, but with little tenesmus or pain. Blood 
may be mixed with them. 

Vomiting is slight, but soon becomes obstinate, and consists 
of clear " rice-water" fluid. Little effort is required in vomit- 
ing. The tongue is dry and covered with a heavy white coating. 
Severe cramps of the legs, feet, hands, and body accompany 
the latter stage of vomiting and purging. Urine is scanty or 
suppressed and contains albumin. Pulse is rapid and there 
is slight fever. 

Collapse (Algid Stage). — At any period from one hour to 
several days after the onset the temperature in the mouth 
and axilla falls from 89° to 80° F. ; the skin is cold • breath 
feels cold ; respiration is rapid and shallow ; great restless- 
ness 5 diminution or loss of voice ; continued vomiting ; eyes 
sunken and hollow ; general wasted appearance ; purging may 
cease, and the mind remains perfectly clear. Vaginal or rec- 
tal temperature may be 103° F., during collapse, while that of 
the mouth and axilla may be 90° F., or lower. Collapse may 
last from six to twenty-four hours, when death comes or reac- 
tion sets in. 

Reaction. — Temperature begins to rise, and may reach 105° 
F. j pulse strengthens; vomiting and purging cease; skin 
begins to get warm, and assumes a more natural appearance ; 
urine is increased in amount, and may show albumin and 
casts ; msij be a rash of erythema or urticaria on the trunk, 
arms, and legs, which lasts for several days. Rapid recovery 



GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 75 

or slow convalescence with a typhoid condition for several 
weeks. Complications may occur at this time — bed-sores, pneu- 
monia, parotitis, and abscesses. 

Pathology. — The weight of medical testimony points to the 
comma bacillus of Koch as the true cause. It develops in the 
gastro-intestinal canal, and produces the various symptoms 
by a process which is unknown. Rigor mortis persists for a 
much longer time than usual. Decomposition is delayed. 
Lungs and serous membranes are congested and red. Intes- 
tines are congested and swollen. Pyer's glands are promi- 
nent, and contain an opaque fluid. All glands in the intes- 
tines are enlarged, and the tissues relaxed. In prolonged 
cases the mucous membrane of the bowel is eroded and 
ulcerated. Kidneys are enlarged as in acute Bright's disease. 
Spleen is diminished in size. 

Diagnosis. — Cholerine consists of a choleraic diarrhoea or 
the symptoms of the onset of true cholera • absence of intense 
muscular cramps and collapse ; short in duration ; absence of 
albuminuria and ursemic symptoms. 

Arsenical poisoning is distinguished by the history; short 
duration; presence of arsenic in dejecta; not epidemic, and 
absence of comma bacillus of Koch. 

Prognosis. — True Asiatic cholera is mostly fatal within six 
hours to seven. days. Epidemics vary in mortality and sever- 
ity. Convalescence is prolonged and tedious. 

Treatment. — Prophylaxis. — During an epidemic use noth- 
ing but thoroughly sterilized water, milk, and food. Light 
wines may be used, but not the stronger alcoholics. Excesses 
of all kinds must be avoided. Bowels should be kept active 
by mild salines if necessary. Daily exercise in the open air. 
Close confinement must be avoided. A daily, cold sponge- 
bath before retiring is beneficial. Every case of diarrhoea, 
even if mild, must be treated at once by mild liquid and 



76 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

farinaceous diet, and intestinal antiseptics every two to four 
hours. (Sulphocarbolate of zinc, gr. iij ; salol, gr. iij • beta- 
naphthol; salicylate of bismuth.) If there is purging use 
copious injections of warm water containing an astringent. 
Thoroughly disinfect all stools, isolate patient and attendants 
(see p. 21). 

Active Treatment. — Never resort to the use ofmorplmia or opium 
hypodermically or by the mouth, except as a last resort to relieve 
intense pain. Camphor gives best results and is used in the 
form of a wine. 

Pulv. camphorae gr. Ixxv. 

Alcoholis q. s. 

Vini rubri O j . 

M. Signa. One small wineglassful, to an adult, every hour. 

This often limits vomiting, diarrhoea, and cramps, and pro- 
duces diuresis. 

Salol or sulphocarbolate of zinc, gr. v — x, every hour, are 
the best remedies, and should be pushed to their full extent. 
Dilute sulphuric and hydrochloric acid should be used in the 
water that is given. 

Enteroclysis or thorough washing out of the bowel. Use a 
fountain syringe, without much pressure, and inject two to 
four quarts of water (100° to 105° F.) to which have been 
added tannic acid, 3ij, and wine of opium, ffij to Oij. If 
possible make the injection, which should always be given in 
the recumbent position, pass the ilio-caecal valve. Repeat the 
process hourly, or keep up a constant flow if necessary. The 
use of antiseptics in enteroclysis is objectionable on account 
of toxic symptoms. 

When the skin becomes inactive and cold, and collapse is 
threatened, rub the body for a few minutes with a rough towel 



GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 77 

and cold water, and follow at once with a hot bath (118° F.) for 
ten or thirty minutes, using the camphor- wine and other stimu- 
lants as indicated. Intravenous injections of a normal aseptic, 
saline solution (seven parts to one thousand, at 102° F.), or Irypo- 
dermic injections of saline solution into the subcutaneous tis- 
sues (hypodermoclysis). Harkins recommends the " application 
of blistering fluid behind the ear and along the course of the 
pneumogastric nerve as far as the angle of the jaw." It has 
been shown to stop purging and other characteristic symp- 
toms and tide the patient over the worst stage of the disease, 
cure or abort it. As soon as stomach and bowels react, ad- 
minister concentrated, predigested meat juices and milk at 
intervals of three or four hours. 



DIPHTHERIA. 

Synonyms. — Malignant sore throat ; membranous angina j 
putrid sore throat ; synache maligna. 

Definition. — An acute, systemic, specific, contagious, epi- 
demic or endemic disease, recognized by constitutional symp- 
toms, albuminuria, and the presence of a tough, ashy or gray- 
ish-white false membrane on the mucous membrane of the 
fauces and throat, and terminating with characteristic sequela?. 

Etiology. — Caused by a germ whose identity is not posi- 
tively demonstrated. Most common among children from the 
second to the tenth year, but may occur in adults. A disease 
of cold weather, and is epidemic. Directly contagious from 
saliva, breath of patient, or from soiled clothing. Filth, made 
ground, bad hygiene, and crowding favor its development. 
The germs may be conveyed in water, milk, food, or ice. 
Cats and pet animals frequently carry it. Period of incuba- 
tion varies from two to six days. 



78 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Symptoms. — Onset may be gradual, with loss of appetite, 
headache, muscular soreness, slight fever, and to all appear- 
ances an ordinary sore throat. It may begin suddenly with 
a chill, chilly sensations, headache, backache, rise of tempera- 
ture to 102° F., enlarged cervical glands, sore throat, painful 
deglutition, great prostration, and coated tongue. During 
the first few hours or days the throat is red, congested, and 
swollen, and shows one or more white points on the tonsil, 
fauces, or palate. These spots may enlarge rapidly, and cover 
half of the throat in twelve or twenty-four hours, or spread 
slowly. This exudation ov false membrane is an ashy or gray- 
ish-white ; quite thick and tenacious ; is hard to detach ; leaves 
small bleeding points and soon reforms. In one or two days 
the throat begins to ulcerate ; breath is very offensive j bits of 
the membrane are coughed and spit up. A part or the whole 
of the throat may be involved. 

Lymphatic glands, at the angle of the jaw, enlarge and are 
very tender ; temperature rises to 104° to 105° F. ; pulse is 
weak, and prostration marked. Urine is scanty, high-colored, 
and contains albumin and casts. The membrane may extend 
to the nasal cavity (nasal diphtheria), and is recognized by an 
excoriating discharge, occlusion of the nose, epistaxis, great 
fetor, and frontal headache. It may extend to the larynx 
(membranous laryngitis; membranous croup), and is recog- 
nized by hoarseness, loss of voice, and croupy symptoms. 
May extend to bronchi ; Eustachian tube to the middle ear ; 
through the lachrymal duct or forward into the mouth. 
Scratches, blisters, and sores on the patient soon become 
covered with a frosty, ashy-white exudation, and ulcerate 
freely. Lymphatic glands may suppurate. 

Resolution may begin on the third to seventh day ; the mem- 
brane gradually disappears ; fever and headache lessen, and 
patient convalesces very slowly. Relapses are frequent. En- 



GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 79 

docarditis may develop. Sudden death from cardiac embolism, 
paralysis of the heart-muscle, or asphyxia. Diphtheritic paraly- 
sis, temporary or permanent, always follows typical cases, and 
may affect the muscles of deglutition, with inability to swallow 
and regurgitation of the food ; loss of voice, with strabismus 5 
hemiplegia or paraplegia j paralysis of the bladder ; and local 
anaesthesia. Duration of diphtheria is two to three weeks. 

Pathology. — Diphtheria is caused by a germ which seems 
to nourish best in the mucous and submucous membranes of 
the throat, nose, and bronchi. The false membrane is com- 
posed of mucus, epithelium, leucocytes, new fibrous tissue, 
pus-corpuscles, micrococci, and bacilli. It is tough, tenacious, 
ashy-white in. color, when detached leaves bleeding points, 
and soon reforms. This membrane grows in successive layers, 
and spreads from one or more focal points to the pharynx, 
larynx, lungs, mouth, ears, eyes, or nose. The submucous tis- 
sue is infiltrated with leucocytes and germs. Absorption of 
ptomaines produces all constitutional symptoms. Diphtheritic 
endocarditis is due to the introduction of the germs into the 
circulation. Paralysis is probably due to multiple neuritis. 
The enlarged glands show bacteria and inflammatory changes. 
Heart and kidneys are more or less degenerated. Albuminuria 
is always present in typical cases. 

Diagnosis. — Scarlatina is abrupt in onset, with very high 
fever, sore throat, no tough membrane in the throat, and the 
appearance of the characteristic eruption in twenty-four hours. 

Follicular tonsillitis is recognized by small yellow plugs, fill- 
ing the follicles of one or both tonsils, which do not spread 
to the palate and mucous membrane ; different course, dura- 
tion, and sequelae ; few constitutional symptoms, and no gen- 
eral glandular enlargement. 

Prognosis. — Must always be guarded, as most favorable 
indications are often replaced by severe and fatal symptoms. 



80 A SYNOPSIS OP THE PRACTICE OP MEDICINE. 

Always advise patients and parents of possible endocarditis, 
cardiac paralysis, Bright's disease, or local paralysis. Laryn- 
geal and nasal diphtheria are very unfavorable. 

Treatment. — Isolation is imperative. Rest in bed from the 
onset nntil all traces of the disease disappear. Avoid all de- 
pressants, and give nothing bat stimulating and tonic treatment. 

Dietary Treatment. — Nourishment must be given at regular 
intervals of four hours, day and night, regardless of sleep. 
Milk is the best diet. With it you may give beef-extracts and 
beef -juices, brandy, or an egg. Administer brandy (gtt. x-lx) 
each time milk is given, if there is much prostration. Scraped 
beef, in small amounts ; boiled rice, tapioca, and sago j light 
puddings ; wine-whey, wine- jelly, chicken- jelly, baked potato, 
soft-boiled egg, and juice of oranges. Avoid all heavy, indi- 
gestible diet. Rectal alimentation may be necessary. 

Internal Medication. — Hydrargyrum chloridum corros., gr. 



to 30 , and tr. ferri chloridi, gtt. x-xx, every three to six 



60 



hours, pushed to a point short of mercurialism. Infusion of 
digitalis may be given at four-hour intervals for its stimulating 
and diuretic effects. Potassii chloras, gr. j-v, every three or 
four hours, with tr. ferri chloridi, is an old method, but rather 
depressing, irritating to the stomach and kidneys, and unsatis- 
factory in many cases. Hydrargyri ioclidum rubrum, gr. T J- - 
to -<f -, every two to four hours, is recommended. Salol, qui- 
nine, turpentine, acetanilide, phenacetin, and many other 
drugs are recommended. Keep the bowels active with 
salines. Stimulate freely. Fever must be met with local 
cleanliness of the throat and cold sponge-baths. Avoid de- 
pressing antipyretics. Paralysis demands tonics of strychnine, 
iron, arsenic ; massage and galvanism to the affected parts. In 
diarrhoea give calomel, gr. -£- - to xb", every two hours for 
twelve hours, and if not checked give sulphocarbolate of 
zinc or salol every two hours. 



GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 81 

Local Medication. — The nose and throat must be kept thor- 
oughly clean, and local applications made at regular intervals, 
night and day. 

Hydrogen peroxide. .(15 to 30 volume), f^ij. 

Grlycerini f^j. 

Aquae q, s. ad. f § vj. 

M. Signa. Use locally as a gargle, application, or spray, 
every half -hour, until the growth of the membrane is checked, 
then continue at hourly intervals as necessary. If too strong 
dilute with one part of water. 

Unless gargling, mopping, or spraying is done thoroughly 
and regularly, good results are impossible. Solutions of lactic 
acid, papoid, pepsin, pancreatin, trypsin, carbolic acid, iodine, 
chlorate of potash, and iron, find their advocates. Ulcers may 
be touched with a solution of nitrate of silver, gr. x-3j, and 
covered with aristol and boric acid. Avoid caustic applications 
to the whole throat. Treat nasal diphtheria by injections and 
douches of alkalies, and follow with peroxide treatment. En- 
larged and inflamed cervical glands are best reduced by a ten 
to twenty percent., ointment of ichthyol, applied thoroughly, 
every four to six hours, followed by the application of dry 
heat. Laryngeal diphtheria is treated as membranous croup. 
Inhalations of hot steam, impregnated with eucalyptol, 
turpentine, or menthol, are desirable and soothing to the 
throat. 

PERTUSSIS. 

Synonyms. — Whooping-cough or hooping-cough. 
Definition. — An acute or subacute, self -protective, conta- 
gious, epidemic disease of childhood, recognized by irregular 



82 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

paroxysms of spasmodic, convulsive coughs, followed by crow- 
ing inspiration or a whoop. 

Etiology. — It seems to be caused by some microorganism 
whose identity is unknown. A disease of children under ten 
years, but may occur in adults. Contagious and epidemic. 
Most common in the fall and spring. Period of incubation 
varies from two to fourteen days. 

Symptoms. — Onset is that of an acute cold, with suffused 
eyes, coryza, slight cough, temperature 99° to 100° F., pulse 
rapid, restlessness, and anorexia. Cough increases, is dry and 
hacking, unsatisfactory, and worse at night. Frequent sneez- 
ing j tickling and burning in the throat. Thus it continues 
seven or eight days, when it assumes a characteristic phase 
known as whooping. 

Without warning, the child suddenly runs to its mother or 
tightly grasps some near article, gives one or two short spas- 
modic coughs, and then ten to twenty expiratory coughs in 
succession, without inspiration, followed by a long-drawn crow- 
ing inspiration or whoop, and several barking coughs. Dur- 
ing a paroxysm the face is dusky, eyes prominent and con- 
gested, and veins of face and neck prominent. Vomiting not 
infrequently follows the paroxysm. Hemorrhage from the 
nose, mouth, bronchi, or into the skin, may accompany or fol- 
low violent paroxysms. Paroxysms varjr in number from two 
to fifty in twenty-four hours, and the child seems almost well 
in the intervals. This stage may last three weeks to six months, 
and subsides by lysis, leaving nervous sequelae, disordered 
digestion, tuberculosis, anaemia, and general debility. Com- 
plications are bronchitis, catarrhal pneumonia, emphysema, 
atelectasis pulmonum, severe hemorrhages, vomiting, and sub- 
lingual ulceration. 

Pathology. — Analogy would show that whooping-cough 
was due to a microorganism, but none has been isolated. 



GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 83 

The neurotic element enters into it largely, and the paroxysms 
are probably caused by an irritation of the vagus nerve. The 
tracheal and bronchial glands are enlarged. Very little of the 
true pathology is known. 

Prognosis. — Death from the disease itself is rare, but may 
be caused by hemorrhage or any of the complications. Its 
average duration is six weeks, but may continue three or six 
months. 

Treatment. — It is rarefy necessary to put the child in bed, 
but it should be protected from exposure to cold and wet. Iso- 
late the child as much as possible. Bromoform forms the basis 
of my treatment, and is followed by the very best results. 

Bromoformi . mxvj. 

Alcoholis f 3 ij. 

Glycerini f 3 xij. 

Tr. cardamomi comp ad. f lij. 

M. Signa. One teaspoonful every two to four hours, to be 
continued throughout the disease, and dose increased or dimin- 
ished as necessary to control paroxysms. 

Tr. belladonna, increased to the point of tolerance, is an old 
and valuable method of treatment. Bromides, chloral, hydro- 
cyanic acid, acetanilide, phenacetin, and other antispasmodics 
are used. Inhalations of hot steam, impregnated with thy- 
mol, eucalyptol, carbolic acid, tr. -iodini comp., or camphor, 
give much relief. Avoid dry furnace heat. It is advisable to 
air rooms daily and impregnate the air with medicated steam. 
Local applications to throat are of no use. Treat all compli- 
cations as they arise, and regulate diet to digestive ability. 
Small doses of arsenite of copper, gr. toVo? every hour, have 
given good results in reducing the number of paroxysms. 



84 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 



PAROTITIS. 

Synonyms. — Mumps. The French call it Oreillous, and the 
Germans Ziegenpeter. 

Definition. — Parotitis or mumps is an acute, contagious, 
specific inflammation of one or both parotid glands, and is 
most common in children from five to fifteen years. 

Etiology. — Idiopathic parotitis (mumps) is supposed to be 
due to a germ that has a period of two or three weeks' incuba- 
tion. Epidemic, and most common in males. It is self-pro- 
tective. Contagion is said to take place through the breath. 
Symptomatic parotitis is a concomitant of some other disease, 
and should never be termed mumps. Due to pyaemia, diphtheria, 
and septic fevers, such as t} 7 phoid, typhus, etc. It is a sequela 
of influenza. 

Symptoms. — Commences with a chill and fever. There is 
headache, constant thirst, sometimes vomiting and lassitude. 
Temperature may reach 103° F. Jaws become stiff in a few 
days, and pain is felt under the ear. Parotid gland is tender 
and swollen. Submaxillary glands are swollen and tender. 
It begins on one side, and may spread to the other. Swelling 
continues for six days, is stationary for two or three days, 
and runs its course in about eleven days. Masticatiou, talk- 
ing, sour food or drink will cause intense pain in the gland, 
on account of stimulating it to activity. May terminate in 
resolution or suppuration. Fever is always higher when sup- 
puration is present. 

By metastasis, inflammation may suddenly leave the parotid 
gland and appear in the testicle, meninges of the brain, or, if in 
the female, in the ovaries of mamma ; but this is rare. Pulse 
is usually quick j urine scanty and high-colored. Side of the 
face is red and swollen. Salivation and loss of hearing are 



GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 85 

frequent. Shooting pains are felt in the ear. Facial paral- 
ysis, from involvement of the portia dura. If temperature 
continues after the decline, be on the watch for metastasis. 
Urethritis may complicate. 

Pathology. — Mumps. — An inflammation due to a germ, and 
extending through the salivary ducts, causing an involvement 
of the parotid gland and its tissues. Redness, heat, pain, 
swelling, and perverted function. Tissues around the gland 
may be involved. There is an exudation into the gland and 
surrounding tissues, which may be absorbed or give rise to 
suppuration and destroy part of the glandular function. 

Symptomatic parotitis is always metastatic, and results in 
suppuration, with destruction of part or the whole of the 
gland. 

Diagnosis. — A sour pickle or lemon makes diagnosis certain, 
but is a very painful procedure. It can hardly be confounded 
with other troubles. 

Prognosis. — Is favorable, and is rarely fatal. In metas- 
tasis the function of the testicle or organ involved may be 
destroyed. Duration is about eleven days. Symptomatic par- 
otitis usually means suppuration, and may be deafness. 

Treatment. — No specific. Absolute rest in bed. Low, non- 
febrile, liquid diet, such as beef -tea, soups, yelk of egg, milk, 
or custards. Allow no solid food and no seasoning. Wrap 
the side of the face in raw cotton or wool. Fever mixture 
or sponging the body with tepid water. Cathartics of sodii 
phosphas or Rochelle salts. Bartholow recommends extrac- 
tum jaborandi fluid., gtt. x-xxx, to abort the disease. Grray 
powder, gr. J, three or four times a day, will relieve swelling 
and pain. Inunctions of hot lard and turpentine, belladonna, 
or glycerin. Hot fomentations to the gland will relieve pain 
and facilitate formation of pus. Evacuate pus as soon as 
detected. Tn prostration, give stimulants and apply warmth 



86 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

to the extremities. Pyoctanin, ten-percent., solution, or hy- 
drogen peroxide, applied to the abscess when opened, will stop 
suppuration. Sulphide of calcium, gr. iV, every three hours, 
to prevent suppuration. 

In orchitis or mammitis apply poultices or leeches, and 
treat symptoms. In symptomatic parotitis apply poultices and 
leeches, and give the best diet, fresh air, and exercise during 
convalescence. 

TETANUS. 

Description. — Tetanus is a spasmodic and tonic muscular 
contraction of certain groups of muscles, accompanied by pain 
and rigidity. It may occur at any age, and usually follows 
traumatism (traumatic tetanus). It may follow a mere scratch, 
the entrance of a splinter, or a severe wound. May occur in 
babies (tetanus neonatorum). Exposure to cold and wet. May 
occur without any apparent cause (idiopathic tetanus). 

Onset is slow or sudden, with a sore, tired, and stiff feeling 
in the muscles of mastication and neck, which may continue 
several hours or days, and then extend to the muscles of the 
back and chest — rarely to the extremities. Stiffness and sore- 
ness increase ; muscles contract, become rigid, and draw the 
affected parts into various positions. Muscles of mastication 
become prominent and hard, and lock the jaw so that it can- 
not be opened voluntarily or by mechanical meaiis (trismus 
or lockjaiv). Muscles of expression are contracted, giving 
the face the appearance of laughter (risus sardonicus). Pains 
increase, and become agonizing ; paroxysms of extreme mus- 
cular contraction, lasting several minutes or seconds, occur- 
ring at half -hour intervals ; body is often drawn backward 
until the back of the head and heels touch. Noise, vibration, 
fright, or contact produce paroxysms. Pulse is weak ; tern- 



GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 87 

perature rises as paroxysms increase, and may reach 107° F. 
before death. Delirium is a late symptom. Retention of urine. 
Death is the common termination, and may occur in one to ten 
days from involvement of muscles of respiration or complica- 
tions. Recovery may occur in six to eight weeks. Tetanus is 
probably due to a microorganism. Brieger has made experi- 
ments with a bacillus tetanus, and has isolated several ptomaines 
which produce symptoms almost identical with tetanus. 

Treatment. — Best in bed, avoiding all excitement, bright 
light, noise, and contact. Attention must be given to all 
wounds, and antiseptic measures thoroughly used. Chloral, 
administered in full doses short of its toxic action (twenty to 
sixty grains every four to six hours, per rectum, in warm so- 
lution), will assist in reducing spasms, but often fails. Bro- 
mides are unsatisfactory. Eserine, Calabar bean, and strych- 
nine in full doses are recommended, but are of no value in 
severe cases. Morphine may be used to some advantage as a 
hypnotic and narcotic. Anaesthetics are most serviceable in 
paroxysms to relieve severe pain, when other measures fail, 
but must be used very cautiously. 

Diet must be liquid, stimulating, and nourishing. It may 
be administered per rectum, or food may be passed into the 
oesophagus by a tube introduced through the nose or the 
space left by an extracted tooth. Feed at regular intervals. 
In hyperpyrexia use cold baths, even though they may be at- 
tended by a paroxysm. The urine must be drawn, and the 
catheter should be used cautiously. 

HYDROPHOBIA. 

Description. — Hydrophobia ("fear of water"), occurring in 
man and synonymous with rabies in the dog and lower ani- 
mals, is an acute, infectious disease, transmitted only by di- 



88 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

rect inoculation of the virus through some abrasion of the 
skin or mucous membrane. It usually follows the bite of a 
rabid animal whose saliva is rich in the virus of the disease. 
If the bite is received through thick clothing, the virus is 
often wiped from the teeth and there is no infection. Wounds 
on exposed parts are most dangerous. These wounds and 
abrasions heal readily, and to all appearance get well. Period 
of incubation varies from ten days to several months. 

The attack begins in one of two ways : the healed wound 
or scar begins to itch or burn, and rapidly becomes inflamed 
and painful, for several hours or days preceding the onset ; or 
the wound may show no signs of trouble, but a general feel- 
ing of uneasiness, feverishness, depression, anorexia, and in- 
somnia will appear. There is a tired feeling in the throat, 
followed by slight irritation and difficulty in swallowing, es- 
pecially marked when liquids are taken. There is a general 
spasm of the muscles of deglutition and respiration, caused at 
first by an attempt to take water, later by the mere suggestion 
of water or a slight noise. Later the muscular spasms become 
general. 

SaMva is thick, accumulates in the mouth, and is either ex- 
pectorated or blown from the lips — hence the term " froth- 
ing at the mouth." Temperature rises ; delirium occurs, and 
patient cries out ; imitates the bark of a dog, if his mind is so 
impressed ; attempts to bite or fight those who are about him, 
and is filled with all kinds of maniacal hallucinations. Later 
there is absolute inability to take food ; spasms are very se- 
vere and general, but toward the last may diminish or cease 
entirely, when deep coma and paralysis supervene, and death 
follows. Recoveries are the exception, and the disease never 
lasts more than ten days. 

The pathological changes found consist of an inflammatory 
action at the base of the brain and the medulla oblongata 



GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 89 

There are small hemorrhages, a large collection of leucocytes, 
and inflammatory exudations in these parts. 

Treatment. — Prophylactic. — Many so-called cases of hydro- 
phobia are purely mental in character (psycliropliobia), but, 
nevertheless, fatal. It is never wise to kill an animal the 
moment it has bitten a person. To be certain whether the 
animal was rabid, pen him up for several weeks and carefully 
note his symptoms. Many persons have been needlessly 
frightened and even killed by the mere uncertainty whether 
they had been bitten by a rabid or harmless animal. Make 
all such wounds bleed freely by incisions, thoroughly cauter- 
ize with some acid, and treat antiseptically. 

M. Pasteur, in 1885, devised a method of a successive series 
of inoculations with attenuated virus, for the prevention of 
an attack in those who were supposed to be inoculated. His 
virus is prepared from the spinal cord of rabbits which have 
been inoculated successively with the virus of hydrophobia ; 
first from one, then the other, until a minimum attenuation 
is attained. It is claimed that by inoculating a person, first 
with the weakest virus, then with a stronger, and so on con- 
tinuing until the strongest is used, the disease can be averted 
entirely. Quite a number of " Pasteur Institutes " are now 
using this method, but its efficiency still remains a question 
of doubt. Treat paroxysms as in tetanus (p. 86). 



ANTHRAX. 

Synonyms. — Carbuncle ; malignant pustule ; charbon ; sple- 
nic fever, in animals. 

Description. — Anthrax is caused by the bacillus antliracis, 
which is an aerobic germ about 20W inch long, and repro- 
duces itself by segmentation and the formation of spores. 



90 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

The disease is contracted by direct inoculation or eating food 
which is contaminated by it. Workers on hides, morocco, 
wool, and rags, and butchers are mostly affected. Period of 
incubation varies from one to five days. 

When inoculated through a scratch or wound, there is a 
sensation of itching, burning, and stinging, followed in some 
hours by one or two vesicles which contain a clear, watery 
fluid. The vesicle soon breaks, and assumes an inflamed ap- 
pearance with a dark-purple color. The spot swells, and in- 
volves the surrounding tissues for one or two inches. Small 
vesicles appear on the surface of the swollen area, and several 
points of suppuration form, which ultimately break, leaving 
the carbuncle fall of small suppurating sinuses. The sur- 
rounding lymphatics are enlarged, and frequently suppurate. 
There is fever varying from a slight amount to that of general 
pyaemia. Delirium, great prostration, general pyaemic symp- 
toms, and, in severe cases, death. Mild cases recover after 
prolonged convalescence. 

At times the pustule or carbuncle forms in one of the inter- 
nal organs, producing symptoms which will vary according to 
the organs involved. The internal forms are rapidly fatal. 

Treatment. — A malignant pustule should be deeply incised 
by crucial incisions. Many surgeons follow incision by the 
application of pure chloride of zinc to cauterize the parts. 
After incising freely, constantly wet the parts with peroxide 
of hydrogen or a solution of the acid bichloride of mercury. 
If seen quite early, a carbuncle may be aborted by injecting 
carbolic acid (about two-percent, solution) around its base, 
or by free incisions and cautery. Always follow strict anti- 
septic treatment. Internally, administer iron and quinine in 
full doses. Give most nutritious diet. Alcoholics as in 
pyaemia. Strictly avoid depressants. 



GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 91 



TUBERCULOSIS. 

Definition. — An acute or chronic, infections, contagions, 
specific disease, due to a distinct germ; manifested by the 
formation of nodular masses of caseated or granular cells of 
various sizes (tubercles) in different parts of the body. 

Etiology and Pathology. — The great predisposing causes 
are heredity ; scrofulous diathesis, which is synonymous with 
tubercular diathesis ; pneumonia ; chronic bronchitis ; debil- 
ity; crowding in close houses and mills; a sedentary, indoor 
life ; low, damp climates ; sleeping or associating with tuber- 
culous subjects ; starvation ; over- work ; alcoholism ; exposure ; 
neurasthenia and nervous affections ; syphilis ; diabetes melli- 
tus. Frequently follows child-bearing. 

Exciting cause is the bacillus tuberculosis, first isolated and 
demonstrated by Robert Koch of Berlin, Germany, in 1882. 
The bacillus is blunt at both ends ; produces spores ; motion- 
less ; measures about 3 -5V0 of. an inch in length, and can only 
be seen with a high-power microscope after staining. Laplace 
says: " It falls on a suitable soil; develops at the expense of 
the tissues ; liberates an irritant (ptomaine) which causes pro- 
liferation of cells and inflammation. These cells degenerate, 
necrose, change from a hyaline to a milky or cheesy mass by 
fatty degeneration or coagulation necrosis, break down, and, 
when in the lungs, form a cavity." Bacillus develops in 
epithelial or fibrous tissue ; generates ptomaines, and grows 
best at an average temperature of 98.5° F. For convenience 
of study, Laplace divides tuberculosis into : 

" 1. External or surgical tuberculosis, which comprises lupus 
(tuberculosis of the skin), and tuberculosis of the joints. 2. 
Internal or medical tuberculosis, inclining tiiMr^ulosis of the 



92 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

lungs and of other internal organs." The second class comes 
under our consideration in this work. 

Following is the process of staining bacillus used in the 
Pathological Laboratory of the Medico-Chirurgical College of 
Philadelphia, Pa. : 

u Expeditious Examination of Sputum for Tubercle-Bacilli. 

" 1. Apply a small speck of recent sputum to a cover- glass, 
spread it out thin, and let it dry by waving it to and fro in 
the air. 

" 2. Slightly heat the cover by passing it through the flame 
of an alcohol-lamp, three times, rather slowly. 

" 3. Stain the portion of now thoroughly dried sputum by 
pouring upon it a few drops of the red stain (ZiehPs solution, 
composed of fuchsia, one part ; carbolic acid, five parts ; alco- 
hol, ten parts ; water, q. s., to make one hundred parts). While 
the solution is on the cover- glass, hold it in the flame of the 
lamp and heat until vapor rises. 

"4. Decolorize at once by immersion in water acidulated 
with nitric acid. 

" 5. Pour some alcohol over it, and finish decolorizing by 
repeated immersions in the acidulated water, if required. 

" 6. Pour some distilled water over the specimen, and wash 
it until clear and apparently colorless. 

" 7. Color the background by staining with methylene-blue 
solution. 

" 8. Dry the specimen. 

" 9. Apply to slide and mount in Canada balsam." 

ACUTE TUBERCULOSIS. 

Synonyms. — Acute miliary tuberculosis ; acute phthisis ; 
" galloping consumption." 

Definition. — A general, acute tubercular disease (inflam- 



GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 93 

mation), manifested by the deposit of miliary tubercles in the 
lungs and other organs ; running a characteristic, rapid course, 
and terminating in death. 

Etiology. — Usually hereditary, and when lying latent is ex- 
cited by an acute illness, exposure, over-work, bad hygiene, or 
use of Koch's lymph. Most common in young adults, but 
may occur at any age. Often follows typhoid fever. 

Symptoms. — Begins suddenly with a chill and rapid rise of 
temperature ; or follows some acute illness with chilly sensa- 
tions and gradual onset of fever. Morning temperature is 
99° to 101° F. ; pulse rapid and irregular — sometimes clichro- 
tic; respiration hurried; cough, slight at first, soon becomes 
very hard. Expectoration is frothy mucus, often stained with 
blood; pain in chest, increased b} r coughing. Profuse night- 
sweats, followed by extreme prostration and marked emacia- 
tion. Hemorrhage is not the rule at first, but often occurs 
during later stages. Marked dyspnoea. Diarrhoea from in- 
testinal complication. Symptoms all increase ; delirium ; in- 
volvement of other organs ; and always terminates fatally in 
true cases. Percussion usually clear. May find spots of 
dullness at apex. Brea/thing is vesiculo-bronchial, followed by 
fine, moist and babbling rales. Cavities form in later stages. 

Pathology. — Surface of both lungs is studded with small 
tubercular masses the size of a mustard-seed. Each tubercle 
is surrounded by an inflammatory area, representing the three 
zones of inflammation. Portions of the lung tissue are ne- 
crosed. Small cavities in places. Intestines, spleen, and other 
organs are studded with tubercles. Each bacillus, with its 
product (ptomaine), acts as an irritant; causes congestion, 
cell-proliferation, diapedesis, and a localized pneumonia. This 
cuts off nutrition; prevents proper aeration of the blood; 
causes atrophy and degeneration of lung tissue, accounting 
for caseation, fever, and dyspnoea. 



94 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Diagnosis. — Typhoid fever has characteristic temperature, 
eruption, abdominal symptoms, and absence of bacillus tu- 
berculosis. 

Prognosis. — Acute miliary tuberculosis always terminates 
fatally in less than one year. Cases, so called, that recover 
are not of the miliary type. 

Treatment. — Palliative. Symptomatic. Koch's lymph is ab- 
solutely contra-indicated, as it means certain death in a short 
period after administration. (See Chronic Pneumonia and 
Chronic Tuberculosis. ) 

CHRONIC TUBERCULOSIS. 

Synonyms. — Chronic phthisis • consumption ; tubercular 
phthisis. 

Definition. — A chronic tubercular inflammation of one or 
both lungs, usually limited to the left or right apex 5 recog- 
nized by hectic fever, cough, haemoptysis, and presence of 
bacillus tuberculosis. 

Etiology. — See Tuberculosis and Acute Tuberculosis. 

Symptoms. — Begins insidiously with slight cough, worst in 
winter ; expectoration of frothy mucus, often nummular • im- 
proper chest-expansion ; gradual loss of health and flesh ; las- 
situde and fever in afternoons 5 slight pains in one or both 
lungs; occasional haemoptysis. Following some acute illness, 
pneumonia or bronchitis, prolonged exposure or close confine- 
ment, cough becomes constantly annoying; expectoration 
profuse, often purulent or blood-streaked; marked emacia- 
tion ; constant hectic fever, about 99° to 100° F. in the morning, 
and 101° to 104° F. in the evening; exhausting night-sweats ; 
loss of appetite ; frequent Immoptysis ; diarrhoea ; and a very 
hopeful disposition during the whole disease. Respiration in- 
creased; prolonged expiratory sound; crepitant, subcrepi- 



GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 



95 



tant, and crackling rales ; later, vesiculobronchial breathing 
and moist rales. Percussion dullness, mostly limited to left 
apex. 

During later stages cough increases j dyspnoea ; prostration ; 
peculiar red line along border of gums (gingival line) ; club- 
bing of fingers and bluish color to nails ; oedema of lower ex- 
tremities. Secondary involvement of other organs. Presence 
of bacillus tuberculosis. 

Pathology. — Simply that of tuberculosis, already given, q. v. 



Chronic Bronchitis. 

Little or no dullness at 

apex. 
Slight constitutional 

disturbance. 
No haemoptysis. 

No tubercular family 
history. 

No fever. 

Absence of bacillus 
tuberculosis. 

Very slight or no ema- 
ciation. 

No night-sweats. 

No cavities in lungs. 
Bronchial rales. 

No local manifesta- 
tions. 

Last for years. 

No reaction with Koch's 
lymph. 



Diagnosis. 

Pneumonic Phthisis. 

Dullness at any part of 
the lung. 

Constitutional disturb- 
ance. 

No haemoptysis as a 

rule. 
No tubercular family 

history necessary. 

Fever in afternoon ; no 
fever mornings. 

Absence of bacillus 

tuberculosis. 
Emaciation, varying in 

degree. 

Night-sweats. 

Cavities present. 
Broncial and friction 
rales. 

No local manifesta- 
tions. 

Last for years. 

No reaction with Koch's 
lymph. 



Tubercular Phthisis. 

Dullness at left or right 
apex. 

Marked constitutional 
disturbance. 

Frequent haemoptysis 
is symptomatic. 

Tubercular family his- 
tory. 

Constant fever, worst at 
night. 

Bacillus always pres- 
ent. 

Marked emaciation. 

Profuse, colliquative 
night-sweats. 

Cavities. 
Subcrepitant rales. 

Enlarged glands ; lu- 
pus ; eoxalgia. 

Usually die within three 
years. 

Marked febrile reaction 
with Koch's lymph. 



Prognosis. — Usually fatal. Life may be prolonged several 
3^ears by proper treatment in bad cases. If treated early, 
complete cure may result. 



96 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Treatment. — Preventive. — Avoid strictly all close confine- 
ment, study, over-work, exposure, improper diet and climate, 
dust, and intimate association with tubercular subjects. Never 
sleep with tuberculous patients. Insist on best diet ; out- door 
life in proper climate ; plenty of exercise ; daily " lung gym- 
nastics" and full breathing. Improve general health with 
tonics and cod-liver oil, if indicated. Strictly discourage mar- 
riage and intermarriage of persons predisposed to, or who are 
suffering with, tuberculosis. 

When a patient becomes infected with the bacillus, treat as 
already indicated in chronic bronchitis and chronic pneumonia. 
The only hope of prolonging life lies in most nutritious diet, 
change of climate, reduction of fever and cough as indicated. 
Creosote, iodine, oxygen, aniline, sulphureted-hydrogen rectal 
injections, carbon dioxide, inhalations of compressed air and 
hot air, arsenic, and a host of other remedies, so-called spe- 
cifics, have been relegated into obscurity in so far as their spe- 
cific action is concerned, and dependence has been placed on 
symptomatic, climatic, and hygienic treatment. It is abso- 
lutely impossible to administer germicides in sufficient quan- 
tity to kill the bacilli without killing the patient. Koch's 
lymph, the latest remedy at this date, gives some promise of 
new fields of investigation, but cannot be classed as a specific. 
(See Koch's Lymph.) Dr. Thomas J. Mays, believing that 
tuberculosis is largely dependent upon the condition of the 
nervous system, administers sulphate of strychnine in in- 
creased doses until the limit of its physiological toleration is 
reached, and continues this maximum dose for months, with 
the best results and amelioration of many untoward symptoms. 

Brewer thinks that ordinary vaccine virus may mitigate 
the disease. 

Complications are treated as already indicated under proper 
headings. 



GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 97 



TUBERCULIN. 

Investigators have been searching for ages for a specific in 
the treatment of tuberculosis, and although Robert Koch of 
Berlin seems to have found it in laboratory practice, it is 
very doubtful whether it can be used as such clinically. 
Koch, being of an investigative turn of mind, prepared a 
pure culture of the bacilli tuberculosis, thoroughly sterilized 
it with heat, preserved it with glycerin and carbolic acid, and 
gave to the profession, in the year 1890, a "lymph" (tuber- 
culin) to be used in treating tuberculosis. It is dark-brown 
in color, and heavier than water. Tuberculous patients, when 
hypodermically injected with one milligram of the lymph 
diluted with distilled water, responded by a rise of temper- 
ature (varying from 99° to 105° F.) within a few hours, and a 
subnormal temperature on the second day. Governed by 
temperature and reaction, the dose is gradually increased 
every three to five days until temperature ceases to rise. 
The system is then said to be saturated with lymph, and 
the tuberculous process checked (?). Patients apparently 
improve under this treatment. 

When lymph enters the circulation and comes in contact 
with the bacilli, it acts as an irritant, -causes hyperaemia, for- 
mation of new cells, diapedesis, and, when in the lungs, a 
localized catarrhal pneumonia. Tuberculous tissue seems to 
necrose under its action, and is thrown off by cough, is ab- 
sorbed or encysted. Many persons have died from its hasty 
and careless use, and post-mortem shows the cause of death to 
be catarrhal pneumonia or meningitis. Latent tuberculosis 
is brought into activity by its use. Best results have been 
obtained in surgical tuberculosis. Although in the experi- 



98 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

mental stage, without any positive cures on record, we are 
warranted in drawing the following conclusions : 

1. Koch's lymph causes febrile reaction in tuberculous 
patients, and is a valuable means of diagnosis; but owing 
to the fact that it excites latent tuberculosis and causes death 
in some cases, its use in man is questionable. 

2. Lupus and other forms of external tuberculosis improve 
rapidly under its use, and are apparently cured. Time only 
will demonstrate this point. 

3. It must be absolutely avoided in miliary tuberculosis and 
tubercular meningitis. Must not be used in tubercular laryn- 
gitis unless tracheotomy has been previously done or you 
stand ready to perform it. 

4. " We cannot restore destroyed lung- tissue, but if we can 
prevent tuberculosis in the beginning — that is, change the 
tuberculous soil of the patient — we could soon have the dis- 
ease under as complete control as smallpox is to-day." (La- 
place.) 

SYPHILIS. 

Synonyms. — Pox; " bad disease." 

Definition. — A constitutional, contagious, infectious, inoc- 
ulable, acquired or hereditary, venereal disease, recognized by a 
distinct period of incubation and primary, secondary, and terti- 
ary lesions of the skin, mucous membranes, and other tissues. 

Etiology.— -Acquired by inoculation through some abrasion 
on the penis or vaginal mucous membrane during coition. 
The virus may be transmitted by kissing ; from towels, arti- 
cles of dress, or inoculation from any secondary or primary 
source. It is self -protective. Period of incubation varies, but 
is about twenty-one days. 

Symptoms. — Primary. — During the period of incubation 



GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 99 

there are no symptoms. About the twenty-first day there is 
slight burning or itching at the point of inoculation, which 
is followed by the formation of a small, hard papule which 
feels like a shot under the skin or mucous membrane. It 
soon enlarges, becomes indurated, and forms a flat, hard mass 
covered with fine, dry scales, which are soon replaced by an 
open ulcerated surface. This is known as the Hunterian or 
hard chancre. There is rarely more than one primary lesion. 
After pursuing a variable course it heals, leaving a white cic- 
atricial scar. Hard chancre is rarely accompanied by sup- 
purative inflammation in the lymphatic glands, although 
non-suppurative inflammation does occur. The surface of 
syphilitic ulcers has a coppery, raw-meat appearance. 

Secondary symptoms manifest themselves about three months 
after inoculation. An eruption, varying in character, appears 
on the forehead, face, chest, back, and limbs. It may be ery- 
thematous, macular, squamous, papular, vesicular, or pustu- 
lar, is of a coppery or raw-meat hue, and may continue 
from three months to one year, often resulting in scars. Ex- 
crescences or warty growths often form at the junction of the 
skin and mucous membrane of the mouth, penis, vagina, or 
anus. 

Mucous patches or erosions of the mucous membrane of the 
throat and mouth form, and often produce deep coppery or 
frosty ulcers. Sore throat is present with the rash, and varies 
from a mere redness to the appearance of follicular or ulcera- 
tive inflammation. Ulcers are shallow, hardened at the edge, 
slightly undermined, not very painful, and covered with a 
white or coppery detritus. Tongue often cracks and fissures. 
Lymphatic glands in the groin, neck, axilla, and at the bend 
of the elbow, are enlarged and tender, but rarely suppurate. 
Hair falls, but rarely causes complete baldness. Fever is ab- 
sent or very slight. Aching and soreness of the bones is char- 



100 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

acteristic. The eyes are affected with iritis, retinitis, or 
choroiditis. 

Tertiary stage appears in one to ten years after inoculation^ 
and will intermit and remit for an indefinite period. It is 
recognized by late eruptions, gummata, periostitis, and involve- 
ment of the various organs. Macular, erythematous, squa- 
mous, papular, vesicular, or pustular eruptions, similar to the 
secondary stage, appear at any time. Large irregular patches 
of an eczematous nature may form on any part of the body, 
and result in large, infiltrated, coppery-colored ulcers. Nod- 
ules or gummata form in the periosteum, liver, spleen, glands, 
and other parts, and cause necrosis, suppuration, and nervous 
symptoms when formed in the cranium (cerebral syphilis). 
Pains in the bones, muscles, and joints are frequent at night. 
Pregnant women suffering with syphilis often abort; or, if 
they go to term, their children are weak and suffer with con- 
genital syphilis. 

The course of syphilis is irregular, and spontaneous cures 
are never effected. Years of constant treatment are required 
to thoroughly eradicate it. Death is rare during the first and 
second stages, but the formation of tertiary lesions may prove 
fatal. 

Treatment. — In the primary and secondary stages, mercury 
is the one remedy which is almost specific. It must be pushed 
to the verge of tolerance, and its action maintained for two or 
three years to prove curative. Bichloride of mercury, gr. eV 
to 3V, may be given in pill form, four times daily, gradually 
increasing the dose. Protiodide of mercury, gr. £ to J, three 
or four times daily, combined with strychnine and belladonna. 
Hydrargyrum cum creta, gr. j-ij, three times daily. Calo- 
mel is also given. By pushing mercury energetically from 
the time of inoculation or the appearance of the primary lesion, 
secondary and tertiary symptoms can be prevented. If 



GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 101 

mercury cannot be taken by the mouth, it may be given in 
the form of hot inunctions (ung. hydrargyri oleati, ten to 
twenty percent.) three or four times daily; or by hypodermic 
injections of the bichloride of mercury combined with chloride 
of sodium and distilled water, repeated every other day. 
Cleanse all ulcers and treat antiseptically with aristol, iodo- 
form, boric acid, calomel, or oxide of zinc. 

Tertiary Syphilis. — The iodides are of more service than 
mercury. Full doses of iodide of potash or soda, protiodide 
of mercury, syrup of hydriodic acid or syrup of the iodide 
of iron, three times daily, given in plenty of water. Treat 
eruptions with ung. hydrargyri oleati (ten to twenty percent.) 
locally. 

In all cases insist on an active, out-door life ; tonics of iron, 
arsenic, quinine, and cod-liver oil. Syphilitics should not 
marry until they have undergone a faithful course of treat- 
ment of not less than three years. They should avoid direct 
contact with others, kissing, and the use of the same towels 
that others use. In fact, syphilis should be treated as any 
other contagious disease. 

BERIBERI. 

Description. — Beriberi is an endemic, infectious, mildly con- 
tagious disease, characterized by the appearance of multiple 
neuritis, dropsical conditions, anaemia, and peculiar cardiac 
murmurs. In Japan it is known as ~kakke. It is also called 
" asthmatic dropsy " and " Ceylon disease." It is endemic in 
China, Japan, South America, and the islands of the tropical 
Pacific Ocean. Scheube and Baelz claim that it is a " primary 
peripheral neuritis." 

Dr. James M. Anders of Philadelphia has reported two 
cases, and the following points are noted: Early symptoms 



102 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

were pain in the abdomen ; occasional nausea, vomiting, and 
diarrhoea ; heart feeble, with increased area of dullness, aryth- 
mia, and a systolic murmur ; spleen slightly enlarged ; fever 
absent or very mild ; ana?mia ; legs cedematous ; ascites in one 
case; reflexes diminished or lost; areas of the skin become 
anaesthetic ; pain in the legs and joints of the knees in walk- 
ing. During convalescence the cardiac murmurs may disap- 
pear and motor symptoms improve rapidly. The anaesthetic 
condition is the last symptom to disappear, and is often com- 
plete when other symptoms subside. The disease is probably 
due to a specific germ. 

Da Costa says its spread is favored by over-crowding and 
bad hygiene ; that muscular power is often lost in the lower 
extremities, and electro-motor contractility is diminished but 
not lost. One attack strongly predisposes to another for sev- 
eral summers. 

Treatment. — Confinement in bed until all symptoms sub- 
side. If there is diarrhoea, meet it with salol, sulphocarbo- 
late of zinc, and bismuth. In constipation use the salines. 
Sustain and nourish with concentrated beef -juice, milk, eggs, 
red mearts, and albumens. Moderate massage and electricity, 
when acute symptoms subside. Infusion of digitalis with 
strychnine, short of toxic effects. Follow with tonics of iron, 
arsenic, manganese, cod-liver oil, and strychnine. Fresh air 
and daily salt baths. Treatment is symptomatic. 



GENERAL NON-INFECTIOUS DISEASES. 



MYALGIA. 

Synonym. — Muscular rheumatism. 

Definition. — An acute or chronic affection of the voluntary 
muscles and fasciae, recognized by soreness, pain, stiffness, 
diminished functional activity of the parts affected, and not 
accompanied by constitutional symptoms. 

Etiology. — Exposure to cold and wet 5 prolonged muscular 
exertion ; muscular sprains j rheumatic and gouty diatheses. 
Most common in adult life. 

Symptoms and Varieties. — General, — Begins gradually or 
suddenly with a feeling of soreness, stiffness, and pain in one 
or more muscles or groups of muscles, which is recognized by 
every attempt to bring them into functional activity. Pain is 
absent during rest, and is increased by pressure and motion $ 
is always worst after prolonged rest, and tends to diminish, in 
mild cases, after muscular exertion. There are no constitu- 
tional symptoms and no cardiac involvement. Different terms 
are used to express the various groups of muscles affected. 

Lumbago, lumbodynia, is an involvement of the muscles on 
one or both sides of the lumbar region, and is most common 
in old men. Pain is always increased by turning, stooping, 
or attempting to rise to the erect position. 

Pleurodynia, " stitch in the side," involves the intercostal and 
thoracic muscles ; is increased by full inspiration, coughing, 
sneezing, laughing, or use of the arms. Pain is sharp and 
shooting. 

103 



104 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Cephalodynia, cephalalgia, is bilateral ; involves the muscles 
of the scalp ; is increased by elevating the eyebrows and mov- 
ing the scalp. 

Stiffness of the muscles of the neck sometimes amounts to 
a spasmodic wry-neck, and is unilateral. The head is held or 
drawn toward the affected side, and every effort to turn it 
causes pain. 

Treatment. — Rest must be enjoined for as long a time as 
necessary, and a mild, nutritious diet given. Establish free 
action of the bowels by calomel and salines. Encourage dia- 
phoresis by hot drinks, pilocarpine, and pulv. ipecac, et opii, 
or hot-water cloths and bottles. Great relief follows the ap- 
plication of hot cloths, poultices, water-bags, or hot iron. In- 
unctions of hot camphor, jaborancli, and lard, followed by 
dry heat. Stimulating liniments are useful. 

Tr. rhois toxicodendron gtt. xvj. 

Tr. bryoniae gtt. viij. 

Aquae f 1 ij. 

M. Signa. One teaspoonful every one or two hours until 
relieved. 

Full doses of acetanilide, phenacetin, salicylate of soda, or 
pill acetanilide comp. (p. 27) often prove very efficient. Mor- 
phina may be used as a last resort for the relief of pain. 

When it becomes chronic, administer chloride of ammonia, 
gr. x-xv, every four hours. Iodide of potash, colchicum, 
guaiacum, iron, and arsenic are used. A mild faradic current 
— not sufficient to cause contractions — applied to the affected 
muscles is quickly curative. The positive pole of a galvanic 
current applied to the painful area and the negative to a neu- 
tral point affords quick relief. Massage is advisable in chronic 
cases. 



GENERAL NON-INFECTIOUS DISEASES. 105 



GOUT. 

Definition. — A general, acute or chronic, hereditary disease, 
recognized by extreme pain and swelling of one or more of 
the small joints, fever, uric acid in the blood, and the forma- 
tion of tophi about the affected parts. 

Etiology. — Gout is hereditary; most common in middle- 
aged men who lead an inactive, sedentary, indoor life, and 
who partake freely of a rich, albuminose diet, wines, and malt 
liquors. Attacks are frequently brought on by prolonged 
mental activity, anger, dissipation, and lead-poisoning. 

Symptoms. — Amite Gout. — For several days there is a slight 
headache, indigestion, constipation or diarrhoea, and a general 
feeling of uneasiness. Patients can often recognize an on- 
coming attack for several days before it manifests itself. It 
begins suddenly at night, when the patient is disturbed by a 
sharp pain in the metatarsophalangeal joint of one great toe, 
which is increased by motion, pressure, or the slightest jar. 
Pain continues, and is worst at night. Chilly sensations, fever 
of short duration (101° to 102° F.), nausea, constipation, and 
increased heart-action. The affected joint becomes swollen, 
red, and extremely sensitive ; the veins of the leg and foot are 
prominent, and muscular spasms of the calf of the leg occur. 
Urine is very high-colored, scanty, acid in reaction ; shows a 
diminution of uric acid, lithates increased, and a deposit 
of a " brick- dust " sediment. Symptoms gradually decline; 
pain and swelling decrease, and the skin over the affected 
joint desquamates. Sometimes two or more joints in the toes 
or fingers are involved. 

In five to fifteen days the patient is well and feels better than 
before the illness. One attack predisposes to another, which 
may come yearly, semi-annually, or be much more frequent. 



106 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Chronic Gout. — Many attacks of acute gout lead to a chronic 
condition, which is recognized by general enlargement of the 
joints of the hands and feet, producing various deformities in 
them. Tophi form about the joints, in the helix of the ear, 
and under various parts of the skin. They consist of hard, 
concretionary nodules of urate of soda and other salts. They 
may inflame, ulcerate, and escape from the skin. There is 
always slight pain in the joints in walking, which is increased 
by damp and stormy weather. Urine is high-colored, and de- 
posits a brick -red sediment. Gout affects the kidneys and 
other internal organs, and manifests itself in many irregular 
forms. 

Pathology. — Gout seems to depend upon an increase of 
urate of soda in the blood, which tends to deposit about cer- 
tain joints, tendons, cartilages, and internal organs, producing 
the symptoms of inflammation present. These deposits and 
tophi are composed of sodium urate, sodium chloride, and cal- 
cium phosphate. The general arterial system becomes athe- 
romatous, and causes hypertrophy of the left ventricle of the 
heart. 

Diagnosis. — Heredity ; sudden onset at night, with, pain in 
one small joint ; condition of urine 5 age, sex, and station in life. 

Prognosis. — Acute gout lasts one or two weeks, is rarely 
fatal, and tends to return at irregular intervals. Chronic gout 
is dangerous on account of atheroma and involvement of the 
kidneys, and materially shortens life by complications or inter- 
current acute diseases. 

Treatment. — Prophylactic. — Take daily exercise in the open 
air, and avoid sedentary habits. Keep bowels active daily. 
Frequent hot baths. Avoid all forms of wines, liquors, and 
alcoholic drinks. An excess of meats and sweets should be 
avoided. All articles of diet that disagree should be avoided. 
Free use of lithium waters is beneficial at all times. 



GENERAL NON-INFECTIOUS DISEASES. 107 

Acute Gout. — Five to fifteen grain doses of acetanilide, phe- 
nacetin, or salicylate of soda, every two to four hours, afford 
great relief to pain. Full doses of vinum colchici, given with 
bicarbonate of soda, every four hours. In very severe pain 
give a hypodermic of morphina. Administer saline or drastic 
cathartics freely. Keep patient in bed; elevate the affected 
parts and bind them with raw cotton. Applications of bella- 
donna, camphor, or soap-liniment often relieve. Lead-water 
and laudanum (U. S. P.), constantly applied are recommended. 
Avoid poultices, cold, and fomentations. Dry heat is best. 
Light milk and farinaceous diet. When acute symptoms sub- 
side, continue treatment with piperazine, gr. xv daily, colchi- 
cum, lithates, or alkalies. 

Chronic Gout. — Free use of lithium waters, piperazine water ; 
active exercise ; prophylaxis as given above. Wine of colchi- 
cum and iodide of potassium, three times daily, give best re- 
sults. Treat acute exacerbations as indicated. 

RACHITIS. 

Synonym. — Rickets. 

Definition. — A constitutional disease, recognized by a pe- 
culiar cachexia and a deficiency of the earthy constituents of 
the bones, producing characteristic deformities and constitu- 
tional disturbances. 

Etiology. — A disease of childhood in both sexes. It is not 
hereditary, but occurs most frequently among the children of 
poor, drunken, syphilitic, or tubercular parents. It may be 
congenital, but is most manifest after the first year. Bad 
hygiene, artificial feeding with improper food, and mother's 
milk, which is deficient in quantity or quality, are active 
causes. 

Symptoms. — Onset is so gradual that it is not recognized 
early. Among the first symptoms is profuse sweating around 



108 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

the back of the head and neck during sleep ; restlessness, un- 
easiness, and tossing when asleep ; slight, persistent diarrhoea ; 
crying and f retf ulness when lifted, carried, or disturbed - } and 
a lack of muscular power. 

The epiphysial extremities of the long bones enlarge — most 
marked at the wrist, knee, and ankle joints. The sternal ex- 
tremities of the ribs show a beaded enlargement on both sides 
of the sternum, making a double row called the rickety ro- 
sary or " beaded ribs." Eruption of the teeth is delayed six to 
twelve months, and when they do appear they soon decay or 
fall out. The bones are soft, elastic, and, by muscular contrac- 
tion and the weight of the body, are drawn out of shape, caus- 
ing bow-legs, prominent sternum with squaring of the upper 
part of the chest (pigeon-breast), narrowing of the pelvis, and 
deformities of the head. Fracture of the bones is rarely com- 
plete (green -stick fracture). 

A rachitic head is flattened laterally, elongated antero-pos- 
teriorly ; forehead prominent, square, and overhanging j face 
small and cramped ; expression is that of an old person j fonta- 
nelles are large, and close late ; veins on forehead are promi- 
nent and engorged. 

The spleen and liver are enlarged and tender • appetite is 
variable j nervous, and prone to convulsions. These cases are 
very susceptible to pneumonia, pleurisy, and intercurrent dis- 
eases which often prove fatal. Recovery may be complete 
without deformity, but most cases retain some deformity 
through life. 

Pathology. — The whole process resolves itself into a lack 
of ossification of the bones, due to an absence of mineral salts 
in the blood. Microscopical examination shows an increase 
and great activity of the number and size of cartilage-cells in 
the bones ; the interstices are filled irregularly with marrow 
and embryonic tissue in place of mineral salts ; the vessels are 



GENERAL NON-INFECTIOUS DISEASES. 109 

enlarged ; the cartilage-cells are irregularly replaced by bony 
tissue, and produce bone which lacks a large percentage of 
normal mineral salts. Section of an epiphysial end and carti- 
lage shows healthy cartilage on one side, almost healthy bony 
tissue on the other, and, interposed, a translucent, pearly-gray 
cartilage, very irregular and greatly enlarged. The spleen, 
liver, and lymphatic glands contain an increase of fibrous 
connective tissue. 

Treatment. — Clothe warmly with medium-weight under- 
clothing. Every night, before retiring, the child should be 
freely bathed in a warm salt-bath, and then rubbed briskly 
with a soft, coarse towel. Follow the bath with an inunction 
of hot cod-liver oil or olive oil. Keep the child in the open 
air as many hours of the day as possible, and, to prevent de- 
formities, do not allow him to bear his weight on the extrem- 
ities. If mother's milk is not sufficient or good, feed with 
cow's milk. Older children require concentrated beef -juices, 
extracts, and scraped beef. Avoid starchy foods. Treat diar- 
rhoea as indicated. Syrup of the iodide of iron and lacto- 
phosphate of lime should be given in full doses, three times 
daily, for many months. Deformities can be remedied by 
surgical appliances, when the child is young. Treat compli- 
cations. 

ACUTE RHEUMATISM. 

Synonyms. — Rheumatic fever; acute articular rheuma- 
tism; inflammatory rheumatism. 

Definition. — An acute, general disease, recognized by fever, 
temporary inflammatory symptoms in one or more joints, in- 
volved successively, and frequent endocardial and pericardial 
inflammation. 

Etiology. — Exposure to cold and wet; bad hygiene and 



110 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

improper clothing. It often complicates scarlatina and preg- 
nancy. Most common in adults. Rheumatic tendency is often 
hereditary. 

Symptoms. — Onset is sudden with a rigor or chill, followed 
by a rise of temperature to 100° or 104° F. ; nausea or vomit- 
ing, and soreness in one or more of the large joints. Other 
cases begin slowly with anorexia, slight headache, and fever, 
followed in a few days by soreness in one or more of the 
joints. Begins in the shoulder, wrist, knee, or ankle joint, 
and spreads until all or most of the large joints are involved. 
The affected joint is bright red, swollen, and extremely sensi- 
tive to the slightest touch, jar, or movement. An effusion 
can be detected in the joint. The sheaths of the tendons 
near the joint often inflame. This inflammatory process may 
be very slight, and subsides in a few days ; or it may be very 
severe, and terminates in resolution in several weeks, with tem- 
porary or permanent stiffness of the joint. 

Fever varies with the number of joints involved and the in- 
flammatory action. In simple cases it is about 102° F., and 
declines by lysis, after many remissions, in one week to ten 
days. Hyperpyrexia (106° to 110° F.) in complicated cases, and 
may continue high for several weeks. Profuse, exhausting, 
sour-smelling, acid sweats ; insomnia ; tongue is broad, flabby, 
and covered with a thick white coating ; urine is scanty, high- 
colored, acid, and loaded with urates. There may be an erup- 
tion of sudamina, small red papules, or miliaria. Rheumatism 
is prone to relapses, and one attack predisposes to another. 

Complications. — Acute endocarditis is recognized by an in- 
crease in fever ; slight or severe precordial pains ; rapid pulse ; 
a soft bruit heard at the mitral or aortic valve, during systole, 
and an increase in the time between systole and the radial 
pulse. It may be slight and disappear in a few days ; may be 
severe and terminate in death or chronic heart-lesions. 



GENERAL NON-INFECTIOUS DISEASES. Ill 

Acute pericarditis is not very common, but is recognized by 
increased fever and pulse-rate ; precordial tenderness and 
pain; dullness on percussion during stage of effusion, and 
friction-sounds on oscultation. 

Single or double pleurisy is not uncommon. Pneumonia is 
the exception. Bronchitis and tonsillitis are often present. 

Pathology. — There is a great difference of opinion as to 
the true cause of rheumatism. There is always an excess of 
lactic acid in the blood, caused by an improper chemical change 
in the albumins, which are normally decomposed into carbon 
dioxide and urea. The nervous involvement is not understood. 
The synovial membranes of the joints are swollen, engorged, 
and covered with a plastic lymph. Synovial spaces are filled 
with a turbid, thin synovial fluid, rich in albumins, shreds 
of fibrin, and leucocytes. The viscera present pathological 
lesions as affected. Late investigation tends to show that it 
is due to a specific germ not yet satisfactorily demonstrated. 

Diagnosis. — GonorrJioeal rheumatism is accompanied by a 
gleety discharge from the urethra ; no fever or heart-compli- 
cations ; attacks one joint, and is very obstinate. 

Pycemia has a history of pyeemic infection; hectic fever; 
involves one joint, which suppurates. 

Prognosis. — Most cases recover. Death may result from 
hyperpyrexia, cardiac complications, or pleurisy. 

Treatment. — Put patient in bed at once, and if pain is 
severe, administer a hypodermic injection of morphina and 
atropina for temporary relief. A free saline or drastic cathar- 
tic should be given and caused to act freely. Put the joints 
at rest, and wrap them in raw, oily cotton. Some prefer the 
application of stimulating poultices, cold applications, sina- 
pisms, blisters, or lead-water and laudanum (U. S. P.) to the 
affected joints. Ichthyol ointment (ten percent.) is soothing to 
the joints. Keep joints covered with raw cotton through the 



112 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

whole disease. Salicylate of soda, ten to twenty grains every 
four hours, is the best remedy for pain and fever, and may 
be given continuously, watching its physiological effects. 
Salicylic acid, salol, or salicin may be given. 

ft 

Sodii salicylates 3 vj. 

Sodii bicarbonatis 3 ij. 

Syr. limonis f 3 ss. 

Aquae q. s. ad. f 3 iv. 

M. Signa. One teaspoonful every two or four hours. 

Acetanilide, gr. v-x, every three hours ; phenacetin, gr. v-x, 
every three hours ; or pill acetanilide comp. (p. 27), every hour, 
gives speedy relief to pain and fever. In hyperpyrexia use 
cold baths freely. Gascara sagrada, combined with the salicy- 
lates or given alone, is an excellent remedy. 

ft 

Ext. cascarae sagradae fluidi f 3 v. 

Sodii salicylatis 3 vj. 

Syr. aurantii rubri f 5 ss . 

Aquae q. s. ad. f § iv. 

M. Signa. One teaspoonful every three or four hours. 

One-drop doses of tr. bryonia and tr. rhus toxicodendron, 
every one or two hours, are beneficial. 

Alkaline Treatment. — Administer full doses of some alkali 
— potassii bicarbonas — until the urine is alkaline or neutral 
in reaction, and maintain it in this condition until a cure is 
effected. Quinine is advantageous in tonic doses only. When 
fever subsides and convalescence begins, administer tonics of 
iron and quinine, hypophosphites, malt or cod-liver oil. 

Diet should be light and farinaceous ; avoid the red meats 
and albumens. Stimulating food is required during convales- 
cence. 



GENERAL NON-INFECTIOUS DISEASES. 113 



GONORRHEAL RHEUMATISM. 

Description. — A complication occurring in the second or 
fourth week of gonorrhoea, closely resembling acute rheu- 
matism and very obstinate to all treatment. One or more 
joints are painful, red, and swollen for a few days, until the 
disease finally locates itself in the elbow, wrist, knee, or ankle 
joint. Joint is much swollen, very painful, red, and the sur- 
rounding tissues are also inflamed. There is very slight fever 
or constitutional disturbance. It persists much longer than 
acute rheumatism and resists all ordinary treatment. The joint 
may be permanently impaired, or recovers after a long time. 

Treatment. — Oleum gaultheria, in full doses, three or four 
times daily, gives best results in acute cases. Salicylates and 
coal-tar derivatives are of little use. In subacute and chronic 
cases, full doses of the syrup of the iodide of iron, syrup of 
hydriodic acid, iodide of potassium, or protiodide of mercury. 
Tonics of iron, quinine, phosphites, and cod-liver oil. Local 
applications of tincture of iodine, ichthyol ointment (ten to 
twenty percent.), sinapisms, or blisters. Local sedatives may 
be necessary in acute cases. Keep parts at rest. When in- 
flammatory symptoms disappear, use massage, electricity, and 
inunctions of hot cod-liver oil. 

POLYURIA. 

Synonym. — Diabetes insipidus. 

Description. — Polyuria is recognized by an abnormally 
large amount of pale, non-albuminous, non-saccharine urine. 
It may be hereditary ; is most common in children, young 
adults, and males. It may depend upon drinking large quan- 
tities of liquids, diuretics, exposure, injuries to the nervous 
centers, fright, anxiety, debility, syphilis, malaria, and cerebral 



114 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

tumors. Many think it is due to an irritation of one of the 
centers near the floor of the fourth ventricle of the brain. 
Patient has an unnatural thirst ; mouth and tongue dry ; hard, 
scaly skin ; constipation ; an insatiable appetite ; nervousness 
and irritability ; headache and dullness of intellect. Loss of 
flesh and impairment of health follow, if of long duration. 

The characteristic symptom is the urine, which varies in 
amount from four to thirty quarts in twenty-four hours ; is 
pale and clear • acid in reaction ; specific gravity of 1.001 to 
1.006 j daily excretion of urea is increased j sugar and albumin 
usually absent. It pursues an irregular course, and the prog- 
nosis varies with the cause. Death is the result of complica- 
tions. Permanent cures are not the rule. 

Treatment. — Establish activity of the bowels with salines. 
Let diet be nourishing and not too stimulating. If tonics are 
demanded, none are better than strychnine, iron, and arsenic. 
Endeavor to limit the amount of liquids taken by allowing 
the patient small amounts at frequent intervals. Ergot, 
pilocarpine, hydrochloric acid, galvanism, and bromides have 
been used with varying success. In specific cases mercury 
and iodides are indicated as given in syphilis. The curabil- 
ity of each case will depend upon the removal of its cause. 
Patients of this class must avoid a sedentary life and live 
out-doors as much of the time as possible. Salt baths should 
be taken two or three times each week. 

DIABETES MELLITUS. 

Synonyms. — Diabetes ; glucosuria ; melituria. 

Definition. — A general diathetic disease, which pursues an 
uncertain course, and is recognized by polyuria, glucosuria, 
great thirst, emaciation, weakness, and a great susceptibility 
to acute diseases. 



GENERAL NON-INFECTIOUS DISEASES. 115 

Etiology. — Most common in men after the twenty-fifth year, 
and in blondes. May be hereditary. Excesses in malt liquors, 
starches, and sugars may cause it ; venereal excesses j irritation 
of the nervous centers ; and cerebral injuries. 

Symptoms. — General. — Onset may be so gradual that it 
escapes notice. There is a tendency to drink large quantities 
of water ; frequent urination and passage of large quantities of 
urine each time; frequent urination at night; great thirst; 
mouth, tongue, and throat are dry, parched, and red ; sMn is 
harsh and dry ; sweet taste in the mouth ; constipation • in- 
creased appetite ; nervousness ; and great weakness. Emacia- 
tion progresses, but may be absent in many cases for a long 
time. Perspiration causes great irritation and itching of the 
skin. In males there is intense irritation of the head of the 
penis; and in women, extreme pruritis vulva?. There is a 
tendency to the formation of carbuncles and boils. Gangrene 
of one or more extremities may occur. Great predisposition to 
pneumonia, tuberculosis, and ocular defects. Toward the close 
of the disease diabetic coma may occur, and often causes death. 

Coma begins by a diminution of the amount of urine and 
sugar passed ; some abdominal pain ; obstinate constipation ; 
extremities are cold and blue ; heart is weak ; indifference to 
all surroundings ; comatose, but can be roused with difficulty ; 
sighing and unsatisfactory respiratory efforts ; and, rarely, con- 
vulsions. It may continue one to five days, and ends in death. 
Symptoms of Bright's disease may complicate or develop. 

Urine varies in amount from two to twelve quarts in twenty- 
four hours, and is pale and clear ; specific gravity, 1.025 to 
1.045 ; has a sweetish odor and taste ; acid in reaction ; urea, 
phosphates, and sulphates are increased ; acetone, aceto-acetic 
acid, or beta-oxybutyric acid are present. When evaporated 
at a low temperature, glucose may be obtained in distinct crys- 
tals. Grape-sugar or glucose is always present, and varies in 



116 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

amount from a mere trace to ten grains to the ounce. As 
much as seven thousand grains may be excreted in twenty- 
four hours. It is detected qualitatively, as indicated under 
urinary tests. 

QUANTITATIVE TESTS FOR GLUCOSE. 

Fermentation Test. — Take a definite quantity of urine (f § iv) ; 
add to it a small particle of compressed yeast, and accurately 
note its specific gravity and the temperature at the same time. 
Put it in a warm place for twenty-four hours or longer until 
fermentation is complete. Accurately note the specific grav- 
ity of the fermented specimen at the same temperature as 
originally taken. Each degree of specific gravity lost corre- 
sponds to one grain of sugar to the ounce of urine. 

Fehling's Volumetric Test. — Ten cubic centimeters of Feh- 
ling's solution are mixed with forty cubic centimeters of 
water, and brought to the boiling-point. Mix one part of 
urine with nine parts of water, and cautiously add this, drop 
by drop, to the boiling Fehling's solution. When the solu- 
tion is entirely decolorized, the calculation can be made from 
the fact that ten cubic centimeters of Fehling's solution are 
decolorized by 0.05 grains of glucose. Measure the amount 
of urine used to decolorize the ten cubic centimeters of 
Fehling's solution, and calculate. 

Pathology. — No definite pathological process has been de- 
termined. Among theoretical causes is found some irrita- 
tion of the central nervous system in the region of the floor 
of the fourth ventricle of the brain j pathologists have pro- 
duced glucosuria by puncturing the floor of the fourth ven- 
tricle in animals. Others claim that there is an interference 
with the glycogenic function of the liver. No pathological 
lesion of the kidneys can account for it. The liver and kid- 



GENERAL NON-INFECTIOUS DISEASES. 117 

neys may be congested, degenerated, or hypertrophied. No 
definite nervous lesions have been found. 

Diagnosis. — The mere trace of a small quantity of sugar ? 
fonnd once or twice, does not diagnosticate diabetes ; for tem- 
porary, functional glucosuria can be produced by eating as- 
paragus and sugar, or drinking excessive quantities of malt 
liquors. It may also be present after anaesthesia by ether or 
carbonic-oxide gas ; after taking toxic doses of hydrocyanic 
acid, curari, morphina, or mercury; after chorea, typhoid 
and typhus fevers, or diphtheria. Unless symptoms are typi- 
cal and a large amount of sugar is demonstrable, do not make 
a hasty diagnosis. 

Prognosis. — Acute diabetes may terminate fatally in a few 
weeks or months with diabetic coma. Chronic cases may run 
for many years, with occasional remissions. About one half 
of the cases die in a few years from coma. A large per- 
centage die of pneumonia or phthisis, and the remainder of 
Bright's disease and other affections. Pregnancy always in- 
creases the symptoms ; premature labor and death of the 
foetus are common, 

Treatment. — Hygienic. — Active business cares must be re- 
duced to a minimum, and an out-door life followed. Clothing 
must be light-weight, all wool, and appropriate to the season. 
Avoid taking cold and exposure to contagious diseases. If not 
contraindicated, take a weak, tepid salt-water bath daily, to 
be followed by rubbing. Exercise must be moderate, regular, 
and restricted. Must avoid all gaseous, smoky, or close rooms j 
retire eauly and sleep late. Observe scrupulous cleanliness of 
the privates. Unless a physician's directions are followed to 
the letter, treatment will avail nothing. Strict dietary lines 
must be drawn and followed. 

Dietary Treatment. — Avoid the following articles of diet : all 
forms of sugars and starchy foods, such as white bread, ordi- 



118 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

nary brown bread, cornmeal, oatmeal, rice, tapioca, arrowroot 
sago, macaroni, farina, potato, turnips, parsnips, carrots 
pease, cabbage, beans, tomatoes, beets, and all kinds of fresh 
and preserved fruits ; also liver, oysters, Devonshire cream 
large quantities of milk, all forms of malt liquors, sweet wines 
and sweetened drinks. 

Allow any of the following for variety : greens, water-cress 
onions, spinach, the green leaf of lettuce (not the white stem) 
cucumber, radishes, celery, with dressings of mustard, vinegar 
oil, or butter. May use cheese, cream (Devonshire excepted) 
any form of meat except liver j game, poultry, eggs, fish, beef- 
extracts, and soups that are not thickened with white flour or 
starch 5 turtle-soup and unsweetened jellies; gluten-bread, al- 
mond-flour bread and rolls, bran-bread and rolls, custards 
without sugar. As drinks, allow pure water, soda and min- 
eral waters, tea, chocolate, coffee, or cocoa, without sugar, but 
with cream ; dry sherry wine, claret, brandy, or whisky. A 
small amount of milk or oysters can be given occasionally 
but may have to be discontinued. Dr. Solis-Cohen allows 
lgevulose or fruit-sugar in moderation, carefully watches the 
urine, renders the blood alkaline, and keeps bowels active with 
phospha,te of soda. 

Medicinal Treatment. — Opium and its derivatives seem to 
diminish the tendency to the formation of glucose, and may 
be given in »small doses three or four times daily. Carbonated, 
alkaline waters, carbolic acid, bromides, dilute nitric acid, and 
almost every drug have been used without avail. Tonics of 
iron, arsenic, strychnine, and cod-liver oil. Local irritation of 
the skin and privates must be met by cleanliness and applica- 
tions of boric acid, oxide of zinc, and aristol. Coma will not 
often respond to active treatment, but free stimulation and 
warmth are indicated. Meet complications. Nitrate of pilo- 
carpine, gr. - 6 -V, three times daily, for the great thirst. 



DISEASES OF THE CIRCULATORY SYSTEM. 



DISEASES OF THE HEART. 

Normal Anatomy and Physiology. — The heart is a hollow, 
conoidal, muscular organ, that acts as a force-pump in keep- 
ing up the normal circulation of blood. It is placed obliquely 
between the lungs, with the apex directed downward to the 
left, and base upward toward the right. Weight is from eight 
to ten ounces. About five inches long and three inches across 
the base. Is about the size of the individual's closed fist. It 
consists of muscular fibers, arising from the aortic and auricu- 
lo-ventricular orifices, arranged by a vortex motion in two 
layers, with looped and annular fibers, inclosing two auricles 
and two ventricles, each receiving certain vessels that are 
protected by valves. 

Inspection shows slight fullness over heart-area in some sub- 
jects j impulse of apex-beat, in fifth intercostal space to inner 
side of left-nipple line — changed by position, forced respira- 
tion, and physical condition. 

Palpation. — Detect impulse of heart; rhythm; abnormal 
thrills or friction rales. 

Percussion. — A greater portion of the heart is covered \)y 
the lung, but precordial dullness is elicited in a space bounded 
superiorly by upper margin of fourth costal cartilage ; inter- 
nally, by left border of sternum ; inf eriorly, by upper margin 
of sixth costal cartilage ; externally, by a perpendicular line 

119 



120 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

one inch to inner side of left nipple. Dullness is affected by 
emphysema ; cardiac hypertrophy; excessively thick chest- 
walls ; pericardial and pleural effusions. 

Auscultation. — Mitral, or bicuspid ., valves are placed between 
the left auricle and left ventricle ; open into left ventricle, and 
their action is best heard during systole, at apex-beat of heart, 
in fifth intercostal space to the inner side of a line with left 
nipple. 

Tricuspid valves, between the right auricle and right ven- 
tricle, opening into right ventricle, best heard during systole, 
one inch to right of ensiform cartilage. 

Aortic valves, between great aorta and left ventricle, opening 
into aorta, best heard one inch to right of sternum, in second 
intercostal space, during diastole. 

Pulmonary valves, between pulmonary artery and right ven- 
tricle, opening into pulmonary artery, best heard during dias- 
tole, in second intercostal space to left of sternum. 

The normal sounds of the heart are two in number and are 
termed systole and diastole. Systole, or first sound, is produced 
by closure of mitral and tricuspid valves ; contraction of heart- 
muscle and impact against chest- walls ; opening of aortic 
valves and rush of blood through aortic opening. A long, 
dull sound. 

Diastole, or second sound, due to closure of aortic and pul- 
monary valves ; opening and rush of blood through tricuspid 
and mitral openings ; and dilatation of the ventricles. This 
sound is shorter than the first, abrupt and ringing. Imme- 
diately following diastole is a short period of repose, during 
which the heart-muscle rests. 



DISEASES OF THE CIRCULATORY SYSTEM. 



121 



CARDIAC MURMURS. 

General usage accepts the term "cardiac murmur" to apply 
to any abnormal sound other than the normal rhythmical 
sounds of the heart. Murmurs are (1) functional or (2) or- 
ganic. 

(1) Functional Murmurs. — Always systolic; soft in char- 
acter, and best heard over the base of the heart. Due to ex- 
citement ; violent exercise ; unequal tension of chordas ten- 
dineae ; and abnormal conditions of the blood, as in anaemia 
and septic fevers. 

(2) Organic Murmurs. — 1. Obstructive. 2. Regurgitant. 
These are harsh, rough sounds, replacing the normal sounds ; 
not limited to one spot, but best heard over affected valve-area. 

Systolic murmurs are always caused by blood flowing from 
ventricles. 

Diastolic murmurs are caused by flow of blood into the ven- 
tricles. 

TABLE OF CARDL4C MURMURS. 



Time. 



Systolic 
murmurs. 



Diastolic 
mur tours. 



Aortic Valve. Mitral Valve. 



Presystolic 
murmurs. 



Center of 
sound. 



Aortic 
stenosis. 



Mitral 
insufficiency. 



Aortic 
insufficiency. 



Second inter- 
costal space ; 
right margin 
of sternum. 



Mitral 
stenosis. 



Mitral 
stenosis. 



Tricuspid 
Valve. 



Tricuspid 
insufficiency. 



Apex-beat. 



Tricuspid 
stenosis. 



Tricuspid 
stenosis. 



Over ensiform 

cartilage ; 
right border. 



Pulmonary 
Valve. 



Pulmonary 

stenosis. 



Pulmonary 
insufficiency. 



Second inter- 
costal space ; 
left margin of 
sternum. 



122 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



CARDIAC HYPERTROPHY. 

Synonym. — Hypertrophy of the heart. 

Definition. — A pathological condition of the walls of the 
heart, recognized by an increase in their muscular elements 
and usually localized to one portion. 

Etiology. — Any cause that increases the normal amount of 
work thrown upon the heart. Over-stimulation by alcoholic 
chinks, coffee, tea, tobacco, and other stimulants ; plethora ; ex- 
cessive exercise ; constant excitement ; organic valvular lesions ; 
lung-diseases, such as emphysema, tuberculosis, and chronic 
pneumonia 3 Bright's disease of kidneys -, any obstruction to 
general circulation ; endarteritis. Most common in males. 

Symptoms. — Full, tense, bounding pulse ; flushed face ; 
veins congested ; mucous membranes red and swollen ; con- 
junctival vessels injected; dizziness; ringing noises in the 
ears ; headache is frequent ; epistaxis ; disordered digestion ; 
and pulsating carotids. Heart beats regularly ; not associated 
with pain, but attacks may occur ; palpitation rare ; dyspnoea, 
and slight, dry cough. 

Precordial region prominent ; strong cardiac impulse ; low- 
ered apex-beat, nearer median line ; percussion dullness in- 
creases laterally. Systole is prolonged and not as clear as in 
health. Symptoms of causative disease. 

Pathology. — Hypertrophy of the heart-muscle is caused by 
over-activity. This causes over-nutrition or extra suppl} T of 
blood and an increase in the number and size of muscle-cells, 
giving rise to three varieties: 1. Uniform increase of the whole 
heart or cardiac walls, without alteration of cavities. 2. Con- 
centric hypertrophy, in which heart-walls are thickened and 
cavities diminished in size. 3. Eccentric hypertrophy, in which 
walls are thickened and cavities dilated. Left side of heart is 



DISEASES OF THE CIRCULATORY SYSTEM. 123 

most commonly affected. Weight of heart increased, hence 
displaced downward toward median line. Shape varies ac- 
cording to part affected. So long as hypertrophy continues, 
it is termed compensatory hypertrophy ; but when compensation 
fails and the heart-muscle has reached its hypertrophic limit, 
degeneration sets in, with dilatation. Partial hypertrophy is 
always due to mechanical obstruction. 

Prognosis. — Great danger lies in failure of compensation ; 
fatty degeneration ; dilatation ; cerebral apoplexy ; cerebral 
aneurisms ; and pulmonary hyperaemia. Simple cases, under 
proper care, do not necessarily shorten life. 

Treatment. — Dietary. — Discontinue use of alcohol, tobacco, 
coffee, tea, red meats, condiments and stimulants of all kinds. 
Give parched pease ; whole wheat, boiled ; vegetables ; fish ; 
small amount of milk; and limit amount of liquids taken. 
Take plenty of time for meals, and never eat enough to fully 
satisfy the appetite. When secondary organic lesions are pres- 
ent, diet as indicated by symptoms. 

Hygienic. — Must lie down after dinner, and never exercise 
after a meal. Avoid every exertion and excessive, violent, or 
sudden exercise, constipation, and every condition that will 
disturb the circulation through the lungs and abdomen. 
Moderate exercise ; massage. Proper hygiene and diet will 
accomplish more than medicines in most cases. 

Medicinal. — When heart is full, tense, and bounding, with 
threatened cerebral hyperaemia, give full doses of tr. aconiti 
or tr. veratri viridis ; or, in extreme cases, venesection ; but 
the latter procedure brings the patient one step nearer fatty 
degeneration. Constant administration of aconite or veratrum, 
in small doses, or bromides, three or four times daily, with 
proper hygienic and dietar} r measures. When compensation 
fails, must resort to best stimulating diet and cardiac stimu- 
lants as given in dilatation. Symptomatic treatment. 



124 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

CARDIAC DILATATION. 

Synonym. — Dilatation of the heart. 

Definition. — A pathological condition, in which one or more 
cavities of the heart are increased in size, and always depend- 
ent (a seqnela) on some other diseased condition. 

Etiology. — Valvular insufficiency or stenosis; increased 
blood-pressure on weakened heart- walls, due to any obstruc- 
tion in the circulation 5 over- stimulation ; failure of compensa- 
tion in hypertrophy ; fatty degeneration ; myocarditis ; fibroid 
and granular degeneration, following anaemia ; chlorosis ; old 
age ; gout ; rheumatism ; improper innervation. Accompanies 
fevers as a functional dilatation. 

Symptoms. — General venous congestion, with superficial veins 
prominent ; skin bluish j oedema of ankles at night ; liver en- 
larged; bowels constipated; frequent attacks of palpitation; 
chilly sensations ; dyspnoea ; constant cough • hearing rather 
dull ; dull headache ; vertigo ; tongue coated. Pulse weak, 
feeble, often fluttering, and easily compressed. Urine fre- 
quently albuminous, red, and scanty. Dropsy gradually in- 
creases, and becomes permanent. Auscultatory sounds feeble 
and pure, or are replaced by a murmur. Percussion dullness, 
increased to right of sternum ; apex-beat slightly lowered. 
(Edema of lungs, cardiac paralysis, and erysipelas are frequent 
causes of death. 

Pathology. — That of cause. Heart enlarged, mostly over 
right ventricle, and walls often as thin as tissue-paper. Dila- 
tation is (1) simple, with increased capacity of cavities with- 
out alteration of walls; (2) that of increased capacity with 
thinning of walls ; (3) that of increased capacity with hypertrophy 
of walls. Heart-muscle is soft, pale, flabby, and easily rup- 
tured. Venous congestion causes dropsy and hyperaemia of 
different organs. 



DISEASES OF THE CIRCULATORY SYSTEM. 



125 



Cardiac Dilatation. 

History of valvular dis- 
ease, obstructed cir- 
culation, or hyper- 
trophy. 

Weakened circulation. 

No friction-sound. 
Dullness irregular. 

Dropsy and venous con- 
gestion. 

Auscultatory sounds, 
clear and sharp ; 
slight weakness. 



Diagnosis. 



Cardiac Hypertrophy. 

History of increased 
cardiac action. 



Over-active circulation. 

No friction-sound. 
Dullness irregular. 

May be dropsy and ve- 
nous congestion. 

Sounds are strong, clear 
and sharp. 



Pericardial Effusion. 

History of acute pleu- 
risy. 



Circulation not mark- 
edly disturbed. 

Friction-sound at apex. 

Triangular dullness, 
base down. 

No dropsy or venous 
congestion. 

Sounds feeble at apex. 



Prognosis. — Cure is impossible. When fatty degeneration 
occurs, death soon supervenes. Great danger lies in fatty 
degeneration • dropsy ; venous congestion of lungs or brain ; 
erysipelas ; paralysis or rupture of the heart. 

Treatment. — In all cases of dilatation the object in treat- 
ment is to prevent fatty degeneration, which is due to innutri- 
tion. To this end keep the blood as rich as possible, lessen 
the heart's work, and insist on absolute rest for a time. Dry 
diet. Avoid all hard exercise ; excitement ; shock ; sudden 
change of posture • overloading the stomach ; imbibing large 
quantities of hot or cold drinks, as these increase arterial 
tension and may cause rupture of the heart. 

Diet of eggs, milk, oils, butter, fish, grated or scraped beef, 
rice, fruits, vegetables, and predigested foods, if indicated. 
Phosphates and lactophosphates of lime, iron, cod-liver oil, and 
arsenic, for anaemia. Massage, in the lying posture, never con- 
tinued longer than fifteen minutes at any one time. Medium 
walks, a little short of patient's endurance. Inhalations of 
compressed air or oxygen, and uniform climate. Alcohol must 
be avoided, as its stimulating action is only temporary. When 



126 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

dropsy is marked resort to saline cathartics, diuretics, and dia- 
phoretics — always watching the heart. Pulv. digitalis fol., 
gr. J to 1, ter die, or inf usimn digitalis, f 1 ss, morning and even- 
ing, is the best remedy to stimulate the heart. It stimulates 
the heart, empties the veins, diminishes venous congestion, 
forces blood into the arterial system, and acts as a diuretic. 
When accompanied by trinitrin, gr. 5-^, ter die, the untoward 
effect of contracted arterioles is overcome. Alternate digitalis 
with tr. strophanthus, to prevent cumulative action. Strych- 
nin a is the most valuable, continued stimulant and stomachic 
tonic. Caffein, adonis, convallaria, sparteine, and barium chlo- 
ride all stimulate, but not as satisfactorily as the others men- 
tioned. 



FATTY DEGENERATION OF THE HEART. 

Definition. — A pathological process, in which the normal 
proteid matter of the muscular and fibrinous cells of the heart 
is replaced by oil or fat globules. 

Etiology. — Old age; anaemia 5 scurvy; phthisis; cancer; 
phosphorus, antimony, arsenic, and lead poisoning; septic 
fevers ; myocarditis ; innutrition from obstructed coronary 
circulation. A sequela of hypertrophy. 

Symptoms. — Cardiac impulse feeble ; pulse weak and com- 
pressible ; precordial dullness, increased if dilatation is pres- 
ent ; rhythm regular or irregular ; syncope ; dyspnoea ; Cheyne- 
Stokes breathing ; oedema of lower extremities ; venous con- 
gestion ; diminished appetite, with gastric disturbances ; dry 
cough ; loss of flesh ; constipation. Late in the disease, marked 
drops} 7 , and death by heart-failure, rupture, or syncope. At- 
tacks of angina pectoris frequently complicate. Arcus senilis 
present in old persons. Arcus senilis is a fatty degeneration 



DISEASES OF THE CIRCULATORY SYSTEM. 127 

of the margin of the cornea, and is present in the form of a 
small ring- around the whole circumference. 

Pathology. — A true fatty degeneration of the heart-muscle 
is caused by improper nutrition. The proteid matter in each 
muscular cell atrophies, degenerates, and is replaced by glob- 
ules of fat and oil. Muscular striae are obliterated or indis- 
tinct. Whole organ is soft ; friable ; dirty-yellow color • very 
greasy and oily. Ventricles and auricles frequently dilated. 
Coronary arteries degenerated and often calcareous. 

Diagnosis. — Fatty infiltration is not a degenerative change, 
but a deposit of fat around and between the muscular cells. 
Heart-cavities not dilated ; different history of onset in people 
who eat rich food and take little exercise. 

Prognosis. — Very bad. Most cases die, except those occur- 
ring during an acute illness. 

Treatment. — Identical with cardiac dilatation. Strychnina 
is the best stimulant for prolonged administration. 



MYOCARDITIS. 

Description. — Inflammation of the heart-muscle, acute or 
chronic, is due to endocarditis, pericarditis, or septic fevers, 
and is so obscure that a positive diagnosis during life cannot he 
made. It ends by resolution or suppuration. Great pain over 
heart; irregular fever; septicaemia or pyaemia; pulse weak 
and irregular; rigors; spleen and liver swollen; and general 
typhoid condition. Post-mortem, heart is soft, infiltrated with 
pus or serum, or contains sinuses or abscess-cavities, inclosed 
or ruptured into pericardial sac or cavities of the heart. 
Most cases terminate in death in less than one week. 

Treatment. — Symptomatic and supporting, with absolute rest 
in bed. No positive diagnosis ; no positive line of treatment. 



128 A SYNOPSIS OP THE PRACTICE OP MEDICINE. 



ACUTE ENDOCARDITIS. 

Definition. — An acute inflammation of the endocardial se- 
rous membrane, accompanied by a fibrinous or serofibrinous 
exudation, interfering with the normal functional activity of 
the heart. 

Etiology. — Acute articular rheumatism ; Bright's disease of 
the kidneys ; gout ; acute fevers ; diphtheria (diphtheritic or 
ulcerative endocarditis). Accompanies pleurisy, pneumonia, 
pericarditis. May be congenital or idiopathic. 

Symptoms. — Disease runs such an insidious course that no 
definite period of onset can be fixed — the first indication show- 
ing itself in cardiac murmurs. Pain is not a constant symptom 
of endocarditis; may be functional derangement of heart; 
pulse rarely increased in volume, but is increased in number 
of beats ; tendency to venous stasis. Before valvular murmurs 
are manifest the disease can be diagnosed by a peculiar length- 
ening of the period between the heart-beat and radial pulse, from 
the normal of one-eighth second to one-quarter second. Heart- 
action tumultuous. May have slight dyspnoea ; gastric irrita- 
tion ; cough and increased temperature. Auscultation reveals 
murmurs at apex-beat or aortic valves, with first or second 
sound of heart, or both. Disease subsides by lysis in one to 
three weeks, or assumes a chronic course. Sudden paralysis 
indicates embolism. 

Ulcerative endocarditis runs a very acute course, with marked 
valvular murmurs ; high temperature, 105° to 106° F. ; septic 
embolism ; delirium ; great prostration ; and usually terminates 
in death or chronic endocarditis. 

Pathology. — Simple Endocarditis. — An irritant, probably 
some poison in the blood, causes hyperemia of the endocar- 
dium in the left side of the heart usually, followed by swelling 



DISEASES OF THE CIRCULATORY SYSTEM. 



129 



of the membrane and a fibrinous or serofibrinous exudation. 
The whole membrane is rarely affected, but the inflammation 
is limited to a part. Valves of the heart, being" formed by 
reflected folds of the endocardial membrane, become thickened 
and swollen, and with the disturbed function of the chordae 
tendineae and columnae cameae allow regurgitation and valvu- 
lar murmurs. Edges of valves are rough, and cause accumu- 
lation of fibrinous clots (vegetations) that remain permanently 
or are washed into the general circulation, causing embolism. 
Valves become adherent to each other and surrounding struct- 
ures. 

Ulcerative Endocarditis. — Diphtheritic or pyasmic in origin, 
and due to a germ which causes inflammation, ulceration, de- 
struction of valves, and thickening of orifices. 



Diagnosis. 



Acute Endocarditis. 



Distant, soft, blowing sound. 

Heart-sounds distinctly heard. 

No pericardial dullness from effu- 
sion. 

Strong heart-impulse. 

Time of radial pulse delayed. 

Little precordial pain. 



Acute Pericarditis. 



Rough friction-sound, near the ear. 

Heart-sounds indistinctly heard. 

Increased heart-dullness from peri- 
cardial effusion. 

Weak, wavy impulse. 

Time of radial pulse normal. 

Severe precordial pain. 



Prognosis. — Simple endocarditis rarely causes loss of life, 
and terminates in recovery by lysis in one to three weeks, or 
becomes chronic. Vomiting, haematemesis, albuminuria, or 
embolism are bad signs. Septic or malignant endocarditis is 
almost certainly fatal. 

Treatment. — Remedies, aimed directly at endocarditis as a 
pimple disease, fail. Remembering its cause, treatment must 
be directed against the primary disease — rheumatism, Bright's 
disease, and others mentioned ; best hygienic and dietary 
measures; absolute rest in bed; and general symptomatic 



130 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

treatment. Digitalis or aconite, as indicated by the heart. 
Ammonii carbonas aids in absorption, and prevention of valv- 
ular vegetations and emboli. Ice over precordial region for 
tumultuous heart. Leeches and blisters. 

CHRONIC ENDOCARDITIS. — VALVULAR DISEASES. 

Description. — Chronic inflammation of the endocardium, 
most common in the left side of the heart, is the result of 
acute endocarditis, and gives rise to organic lesions in the 
valves and heart-muscle. It is recognized by the presence of 
harsh, continued murmurs, which replace the normal heart- 
sounds, and circulatory derangements. Heart-murmurs are 
caused by valvular insufficiency {regurgitant murmurs) or ste- 
nosis {obstructive murmurs). See table, page 121. 

Insufficiency is an improper closure of the valves, due to 
contraction or deformity ; rupture of the segments ; contrac- 
tion of chordge tendineae j ulceration ; presence of warty ex- 
crescences on valve-leaflets ; or simple dilatation. 

Stenosis is a narrowing of the valvular orifice from inflam- 
matory infiltration, adhesion of segments of valves, and warty 
growths. 

Either trouble may exist alone or be present in the same or 
several valves. Compensatory hypertrophy and dilatation are 
positive sequences of valvular lesions. Congenital endocarditis 
is always on the right side of heart, but is rare. Hcemic 
murmurs are soft and blowing ; transmitted along the veins 
and arteries of the neck; best heard at the base of the 
heart 5 and accompanied by anaemia. 

MITRAL INSUFFICIENCY. 

Description. — Insufficient closure of the mitral valve allows 
blood to regurgitate into the left auricle during systole, and 



DISEASES OF THE CIRCULATORY SYSTEM. 131 

prevents the normal amount of blood passing through the 
aortic opening. This causes a damming back of blood into 
the pulmonary veins and general venous system ; venous con- 
gestion ; arterial anaemia ; hypertroph} T and dilatation of the 
left ventricle. Lungs, liver, spleen, and gastro-intestinal tract, 
are in a state of chronic congestion. Chronic cough ; dysp- 
noea; gastro-intestinal catarrh 5 occasional jaundice ; marked 
anaemia ; pulse irregular, delayed, and soft ; haemoptysis 
and haematemesis ; blowing murmur, during systole, at apex- 
beat. Dropsy comes late, beginning in lower extremities and 
advancing upward as the tissues become loaded with serum. 
When compensatory hypertrophy fails patient dies from heart- 
paralysis, dropsy, or congestion of one or more organs. 

MITRAL STENOSIS. 

Description. — Narrowing of the mitral valves obstructs the 
normal flow of blood from the left auricle into the left ventricle 
daring diastole ; causes damming back of blood in the lungs 
and venous system, with same general symptoms given in 
mitral insufficiency. Blowing, whizzing sound heard at 
apex-beat, immediately following diastole or before systole 
{presystolic). Hypertrophy of left auricle and right ventricle, 
followed by dilatation and death. 

AORTIC INSUFFICIENCY. 

Description. — Insufficiency of the aortic valves allows re- 
gurgitation of blood from the great aorta into the left ven- 
tricle of the heart during diastole ; causes venous congestion ; 
hypertrophy of the left ventricle ; dicJirotic, water-hammer, or 
Corrigan pulse (a full beat which rapidly declines, giving a 
sensation of a double pulsation) • pulsating carotids and reti- 



132 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

nal vessels ; headache ; flushed face ; tinnitus aurium ; anaemia ; 
strong and full cardiac impulse ; increased transverse dull- 
ness from hypertrophy. First sound clear, and second sound 
replaced by a blowing murmur or thrill, best heard at the 
second intercostal space to right of sternum. When compen- 
satory hypertrophy fails there is dilatation, cough, d} T spnoea, 
general dropsy, congestion of internal organs, and sudden 
death. 

AORTIC STENOSIS. 

Description. — Aortic obstruction prevents blood from flow- 
ing freely from left ventricle into the great aorta during sys- 
tole 5 causes damming back of blood, with hypertrophy of left 
ventricle, venous congestion, and the train of sjmrptoms given. 
Pulse rises slowly. Arteries are comparatively empty, caus- 
ing anaemia, with syncope (often fatal) and vertigo. Whizz- 
ing, harsh murmur replaces systole and best recognized at 
second intercostal space to right of sternum, or transmitted 
along the carotids. Disease is most commonly due to athe- 
roma. Death occurs suddenly from syncope or embolism. Dis- 
ease is rarely simple, but complicates insufficiency of aortic 
and mitral valves. 

TRICUSPID INSUFFICIENCY. 

Description. — Insufficiency of the tricuspid valves causes 
regurgitation of blood from the right ventricle into the right 
auricle ; general venous congestion, with dropsy, congestion 
of organs, and concomitant symptoms. Usually follows mi- 
tral disease or any obstruction to pulmonary circulation that 
would cause dilatation of the right ventricle and enlarge this 
valvular orifice. Systolic, blowing murmur heard over 
right inferior part of sternum. Pulsation of jugular reins is 



DISEASES OF THE CIRCULATORY SYSTEM. 133 

symptomatic — veins expand during systole. Cardiac dullness 
increased to the right side of the sternum, due to hypertrophy 
and dilatation. 

TRICUSPID STENOSIS. 

Description. — Obstruction of tricuspid valves is a very rare 
condition, and prevents free flow of blood from the right 
auricle into the right ventricle during sy stole ; causes hyper- 
trophy of the right auricle, general venous stasis, and the 
symptoms of tricuspid insufficiency. Murmur, presystolic, 
over lower right border of sternum. 

PULMONIC INSUFFICIENCY. 

Description. — Pulmonic insufficiency causes regurgitation 
of the venous blood from the pulmonary artery into the right 
ventricle of the heart during diastole ; gives rise to dilatation 
and hypertrophy of the right ventricle, and general venous 
stasis. Congenital, or accompanies malignant endocarditis. 
Loud, blowing murmur at second intercostal space to left of 
sternum during diastole. 

PULMONARY STENOSIS. 

Description. — Pulmonary obstruction retards normal flow 
of blood from right ventricle to pulmonary artery during 
systole. Great dyspnoea; cough; venous stasis and conges- 
tion ; cyanosis ; loss of compensation ; and death. Congenital ; 
hypertrophy of right ventricle. Death occurs within a few 
hours after birth, but some cases have lived for years. 

Treatment. — General Hygienic and Dietetic. — Avoid mental 
and physical strain • sudden motion and exertion ; excitement 
from great joy, grief, and fright ; over-loading the stomach 
with large quantities of food and drink; alcohol, tobacco, 



134 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

coffee, tea; and the too common practice of "home remedies" 
and patent medicines. Encourage regular, daily, systematic 
exercise, short of endurance ; rest in recumbent position dur- 
ing the middle of the day, especially after meals. Never eat 
a full meal, but stop before the appetite is fully satisfied. 
Best nutritious diet, as indicated in cardiac dilatation and 
hypertrophy. 

As long as compensatory hypertrophy continues and no 
venous stasis supervenes, medicinal treatment is con train di- 
cated, except to meet symptoms. Cardiac stimulants must be 
used cautiously. Bowels must be kept open by small doses 
of salines. Keep kidneys active by diuretics. Venesection 
may be necessary in certain conditions of dilatation of the 
right side of heart, with venous engorgement. 

Stimulants. — Alcoholic stimulants and ammonia prepara- 
tions act quickly for temporary relief. Digitalis, alternated 
with strophanthus, increases force of heart ; slows its action ; 
produces diuresis ; strengthens sj^stole and lengthens diastole. 

Aortic Stenosis. — Digitalis must be avoided, as lengthened 
diastole increases the trouble. Atrophias sulphas, gr. -gV, and 
strychnine? sulphas, gr. ^fo, with trinitrin, gr. T ^o, ter die, to 
increase rate and strength of cardiac contractions, to stimulate 
respiration and control arterial tension. 

Aortic Insufficiency. — Digitalis should be avoided. Strych- 
nina, atrophia, caffeina, with trinitrin, are best. 

Alitral Stenosis. — Lengthen diastole with digitalis ; strengthen 
heart-muscle with strychnina, ferrum, and caffeina. When 
complicated with insufficiency, add the nitrites. 

Mitral Insufficiency. — When compensation begins to fail 
digitalis is the best remedy. Alternate it with strophanthus to 
prevent cumulative effects. When blood-pressure is height- 
ened combine trinitrin with digitalis. Treat symptomatically 
in all valvular lesions, 



DISEASES OF THE CIRCULATORY SYSTEM. 135 



CARDIAC PALPITATION. 

Definition. — A spasmodic, paroxysmal, functional, neurotic 
disturbance of the heart, manifested by a marked increase of 
its action, and dependent on some exciting cause. 

Etiology. — Common in childhood j sexual disorders ; hypo- 
chondriasis j over- work ; excitement ; fear or fright ; over-loaded 
stomach ; over-stimulation by coffee, tea, alcohol, or tobacco j 
obesity j gastric disorders ; valvular diseases ; hypertrophy ; 
general anaemia 5 uterine disorders 5 and hysteria. 

Symptoms. — Begins suddenly at night or at any time of 
day, with a violent action of the heart ; a bounding impulse ; 
dyspnoea, increased by recumbent position ; praecordial oppres- 
sion • great anxiety and fear of death j tinnitus aurium j flushed 
face ; dizziness ; occasional attacks of angina j pulse, full and 
increased. Subsides suddenly in five minutes, or may last for 
hours, followed by exhaustion and desire to sleep. Large 
quantities of pale urine frequently passed. 

Prognosis. — Most cases are curable. When dependent on 
organic lesions prognosis is bad. 

Treatment. — Paroxysmal. — Remove cause if possible. A 
full dose of tr. nucis vomicae, gtt. x ; tr. digitalis with bella- 
donna; spts. ammonias aromaticus; brandy or ether, inter- 
nally, often relieves. Severe cases are benefited by a hypo- 
dermic of morphina and atropina, with an application of ice 
or mustard-plaster over chest. Chloral and bromides act best 
when there is a marked spasmodic element present. Ad- 
minister a full saline purge. Hysterical and hypochondriacal 
patients require full doses of valerian or asafcetida, with the 
application of leeches for a mental impression. 

Preventive. — Avoid excitement, over-eating, sexual excesses, 
tea, coffee, alcohol, and tobacco ; running, and ascending steps 



136 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

rapidly. Treat uterine and gastric disorders. Keep bowels 
regular and give tonics of iron, quinine, strychnine, arsenic, 
and cod-liver oil. Best diet, in small quantities; regulate 
hygiene. Seek for and remove every possible cause. 

ANGINA PECTORIS. 

Synonym. — Cardiac neuralgia; neuralgia of the heart. 

Definition. — A paroxysmal neurosis, recognized by intense, 
sharp pain and oppression in the precordial region, with a 
sensation or conviction of impending death. 

Etiology. — Exact cause unknown. Associated with calcare- 
ous degeneration of the coronary arteries and fatty degenera- 
tion of the heart. Hereditary ; hysteria. Sometimes compli- 
cates valvular and aortic disease. Attacks are excited by 
worry, excitement, cold, exhaustion, and sickness. 

Symptoms. — Onset is sudden, with violent, stabbing or dart- 
ing pain over the heart, radiating to the back of the left 
shoulder, neck, and inner side of the left arm, to a point a 
little below the elbow. Patient assumes a sitting or erect 
position ; sensation of strangling or oppression over chest ; 
skin cold and bathed with perspiration ; face pale ; occasional 
sjmcope ; respiration hurried ; vomiting at times ; great anxiety 
and fear of sudden death. Heart's action rarely increased. 
hi five to thirty minutes paroxysm subsides suddenly, leaving 
patient exhausted, weak, and nervous. The sensation of pain 
experienced was expressed by a patient, " as if the heart were 
being tightly squeezed in a vise." Paroxysms may occur once 
in three months or, in severe cases, daily. 

During the interval there are no symptoms of any conse- 
quence, no pain, and general good health. Nervous symp- 
toms develop late, and may terminate in epilepsy, iusanity, 
or death. 



DISEASES OF THE CIRCULATORY SYSTEM. 137 

Pathology. — Exact pathology is unknown. Is commonly as- 
sociated with disease of the coronary arteries and accompanied 
by fatty degeneration of the heart. Pain is dne to a disturb- 
ance of the terminal filaments of cardiac plexus, the pneumo- 
gastric and phrenic nerves, and is reflected to the left arm 
through their sympathetic connection with the intercosto- 
humeral and nerve of Wrisberg. 

Diagnosis. — Intercostal neuralgia has slower onset; less 
pain ; tender points along the course of the nerve ; no cardiac 
disturbance, sensation or fear of impending death; does not 
subside suddenly ; never causes death. 

Cardiac epilepsy, although accompanied by great pain, has 
characteristic muscular twitchings, epileptic aura, and loss of 
consciousness. Pain always follows loss of consciousness. 

Prognosis. — Always grave. Death may occur during the 
paroxysm. 

Treatment. — Paroxysmal. — Prompt inhalation of three or 
five drops of amyl nitrite gives most speedy relief. Hypoder- 
mic injection of morphina and atrophia; ether internally; 
trinitrin and stimulants of brandy or ammonia. Avoid in- 
halations of chloroform on account of its fatal tendency to de- 
press the heart and paralyze respiration. 

Preventive. — Avoid every possible cause, such as excitement, 
fright, anger, over-eating, excessive exercise, and indoor life. 
Remove any suspected cause ; live in open air ; best diet ; in- 
stitute regular habits ; tonics of iron, arsenic, quinine, strych- 
nine, and digitalis. JS r o specific, except it be hygienic and die- 
tetic measures. 

EXOPHTHALMIC GOITER. 

Synonyms. — Exophthalmos ; Graves's disease ; Basedow's 
disease. 



138 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Definition. — Extreme irritability of the heart, complicated 
by enlargement of the thyroid gland and marked protrusion 
or prominence of the eyeballs. 

Etiology. — No assignable cause. Most common in women 
between the ages of fifteen and thirty-five. May follow direct 
injury or neurotic troubles. Hereditary. 

Symptoms. — Onset is very slow. Heart is irritable, and as 
the disease progresses beats forcibly and quickly, as in hyper- 
trophy 5 area of impulse increased; pulsation of carotids; 
pulse from eighty to one hundred and forty per minute ; 
dyspnoea on exertion ; attacks of palpitation. 

Following disturbed circulation, both eyeballs become promi- 
nent and staring ; the eyelids fail to meet, thus causing kera- 
titis and ulceration. Upper eyelid and eyeball do not move 
uniformly. Accommodation not affected. 

Thyroid gland enlarges symmetrically and pulsates, impart- 
ing a thrill to the touch. Systolic murmur heard over the 
gland ; loss of appetite and health ; headache ; vertigo ; hys- 
terical attacks ; slight fever ; cough, increased by pressure of 
goiter. Occasional aggravation of all symptoms. 

Pathology. — No positive pathological process has been 
found or explained by pathologists. The goiter is vascular j 
uniformly enlarged ; may contain cysts or new fibrous tissue. 
Exophthalmos may be due to venous congestion, increase of 
fatty tissue in the orbit, or contraction of the involuntary 
muscular fibers supposed to line the orbit over the spheno- 
maxillary fissure. Disease is probably central in origin. 

Prognosis. — Mild cases may recover entirely, partially, or 
remain stationary for years. Death is due to heart-disease, 
exhaustion, or heart-failure. 

Treatment. — N'o specific. When cardiac stimulants are in- 
dicated give digitalis, belladonna, or strychnine. Aconite and 
veratrum when depressants are indicated. Ergot is of doubt- 



DISEASES OF THE CIRCULATORY SYSTEM. 139 

f ul utility. Mild galvanism over the sympathetic nerve or the 
eyes may be beneficial. Applications of ice over the goiter or 
praa-cordial region when heart is irritable. Bandages applied 
over the eyes may lessen the exophthalmos. Trinitrin has 
been recommended. General symptomatic and hygienic 
treatment. A principle derived from the thyroid gland is 
now being used experimentally with some promise of good 
results. 



DISEASES OF THE PERICARDIUM. 

PERICARDITIS. 

Definition. — An acute or chronic inflammation of the peri- 
cardial serous membrane, accompanied b} r a serofibrinous exu- 
dation, and in some cases an effusion of serum into the peri- 
cardial sac. 

Etiology. — Accompanies rheumatism, Bright's disease of 
the kidneys, tuberculosis, septic diseases, pneumonia, pleurisy, 
erysipelas, epidemics of influenza, or direct injury. 

Symptoms. — Onset is usually insidious, but may be heralded 
by distinct chills or rigors, followed by fever ; pain in precor- 
dial region, influenced b} r respiration, motion, and percussion, 
shooting to left shoulder j dry cough ; dyspnoea j anxiety ; ex- 
cited heart-action ; palpitation. Cardiac impulse marked and 
excited; occasional friction fremitus felt. Auscultation re- 
veals friction-sounds over heart, not influenced by respiration, 
most distinct at the base. 

Second stage, or stage of effusion, begins at the end of the 
first day. Increased dyspnoea and oppression ; nausea and 
vomiting 5 pulse weak and irregular ; hiccup ; dysphagia ; 
syncope ; delirium ; high fever j and nervous symptoms. Im- 
pulse feeble and wavy ; precordial dullness increased, as a 



140 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

triangle with the base downward, below the line of the sixth 
rib ; feeble heart-sounds at apex ; friction-sounds at base. 

Third stage, or stage of absorption. Symptoms all lessen; 
dullness gradually disappears; friction-sounds return; fever 
subsides, but irritability of heart persists for a long time. 
Convalescence is slow. 

Chronic Pericarditis. — When the effusion of acute pericar- 
ditis is not absorbed the disease becomes chronic. Precor- 
dial region bulges ; triangular dullness ; weak heart-sounds, 
with friction-sounds at base ; pain ; feeble heart-action ; 
dyspnoea ; and disturbed circulation. Adhesions between the 
heart and pericardial membrane cause depression or dimpling 
of an intercostal space, usually at apex-beat, during systole. 

Pathology. — Pericardial, serous membrane is dull in color, 
red with the l^peraemia, and covered with an exudation of 
plastic lymph, fibrinogen, and leucocytes, arranged in layers, 
during first stage. Serum soon exudes, in varying amounts ; 
distends pericardial sac; causes dyspnoea; interferes me- 
chanically with heart's action, and is sometimes mixed with 
blood. When fluid is absorbed the pericardial walls come in 
contact and cause fibrous adhesions between the visceral and 
parietal layers. Rarely does the pericardial effusion become 
purulent. Membrane may be studded with miliary tubercles. 
When no perceptible serous effusion is present the case is 
termed dry pericarditis. Myocarditis frequently complicates. 

Diagnosis. — See Endocarditis, page 129. 

Prognosis. — Simple pericarditis is rarely fatal. Complicat- 
ing BrighVs disease, tuberculosis, or septic fevers, it usually ter- 
minates fatally. Sequelce are adhesions between pericardium 
and heart ; cardiac hypertrophy and dilatation. 

Treatment. — Absolute rest in bed ; most nutritious, dry 
diet ; and avoidance of every source of excitement, emotion, or 
worry. Applications of sinapisms, leeches, cups, or ice over 



DISEASES OF THE CIRCULATORY SYSTEM. 141 

precordial region. Medicinal treatment resolves itself into 
treatment of cause. Veratrnm or aconite when heart is tur- 
bulent. Digitalis, strychnine, or belladonna as cardiac stimu- 
lants. Tonic doses of quinine and iron. Control fever with 
pill acetanilide comp. (form, p. 27). Marked dyspnoea calls 
for paracentesis. Great relief often follows the use of diuret- 
ics, diaphoretics, and cathartics, but they must be used with 
utmost caution. Morpliina must be given only as a last resort 
to relieve pain. 

Chronic cases, with adhesions, call for local counter-irrita- 
tion ; potassii iodidum ; stimulants of iron, quinine, and strych- 
nine ; best nutritious diet ; and rest. Paracentesis may be in- 
dicated. 

HYDROPERICARDIUM. 

Description. — Pericardial dropsy is a passive or non-inflam- 
matory accumulation of serum in the pericardial sac, due to 
Bright's disease, valvular heart-diseases, or any obstruction 
to the pericardial venous circulation. The fluid is pale yellow ; 
contains a small amount of albumin, fibrin, and blood. Symp- 
toms are dyspnoea, especially when lying down ; bulging of 
precordial region ; increased dullness, triangular, with base 
down ; indistinct heart-sounds j no friction-sounds 5 dry cough ; 
weak circulation ; accompanies other forms of dropsy. Symp- 
toms of cause. 

Treatment. — Entirely dependent upon cause, and must be 
treated as such. Great dyspnoea may be relieved temporarily 
by paracentesis, but the fluid soon returns. Best dietary and 
hygienic measures. 



DISEASES OF THE BLOOD-VESSELS. 



ANEURYSM. 

Definition. — An abnormal dilatation of the walls of an 
artery, classified as sacculated, fusiform, and dissecting. 

A sacculated aneurysm is one in which the enlarged sac 
communicates by a small opening in one side of an artery 
and forms a distinct tumor. 

A fusiform or spindle-shaped aneurysm is one in which the 
whole circumference of the artery is enlarged for a limited 
area, and not sacculated. 

A dissecting aneurysm is one in which the blood dissects its 
course between the inner, middle, or outer coats of the artery 
for some distance and then reenters it again. 

Etiology. — Atheroma ; arteritis ; sudden straining efforts ; a 
result of syphilis, traumatism, and atrophy. Most common 
in old men from forty to fifty years. 

Symptoms. — General. — Tumor in the superficial areas of 
the body is the first point that attracts attention. It always 
accompanies aneurysms, and varies in size according to its 
duration and the part affected. It may be hard, soft, or com- 
pressible. Always located over the course of an artery. Pain 
of a sharp, shooting, or dull character is almost always pres- 
ent and is increased at times by pressure ; most severe over 
the tumor, and radiates from this point along the course of 
the nerves involved by its pressure. Thrill or pulsation is 
synchronous with the heart's beat, and causes a gentle, rising 

142 



DISEASES OF THE CIRCULATORY SYSTEM. 143 

and falling (expanding and contracting) sensation to the hand, 
often seen by the eye. In addition to this a thrill is often 
imparted to the hand. Recent aneurysms impart a greater 
thrill than those of long standing. 

Bruit, a constant symptom, is best heard over the seat of 
tumor, and varies from a soft systolic or diastolic gurgle to 
a harsh, rushing or thrilling sound. Most prominent in saccu- 
lated aneurysms, and produced by the blood circulating thro ugh 
the narrow opening into a large sac. 

Pressure Symptoms. — Thoracic Aneurysm. — The tumor, as it 
enlarges, presses against the oesophagus and causes difficult 
deglutition ; impinges on the trachea, giving rise to constant 
cough and dyspnoea ; compresses areas of lung- tissue, with 
consequent atelectasis • interferes with normal heart's action ; 
presses on the pneumogastric, phrenic, sympathetic, and other 
nerves, with concomitant symptoms. Pupils often unequal 
from pressure on the sympathetic ; voice changes or is often 
lost. Bulging of sternum or whole thoracic wall in advanced 
cases. Occasional attacks of angina pectoris. Inequality of 
right and left radial pulse. Loss of flesh ; anaemia ; embolism ; 
and, commonly, death from exhaustion, pain, or rupture of 
the sac. 

Pathology. — An aneurysm usually develops in an artery 
at the point where the greatest pressure is brought to bear, 
either from the heart's action or mechanical injury. The 
arterial wall is weak, degenerated, and, by the blood-pressure, 
dilated. The tunica intima soon ruptures, as a general rule, 
leaving the tunica media and adventitia. Blood circulates 
through the dilatation or sac somewhat sluggishly, with a 
vortex motion. This allows a deposit of fibrin on the inner 
wall of the sac, and, if it continues, ultimately fills it, and is 
nature's cure. Other cases continue to enlarge ; cause erosion 
or absorption of bones ; press upon surrounding organs j and 



144 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

ultimately cause death. Coagula formed in the aneurysmal 
sac are liable to be carried into the general circulation and 
cause embolism. 

Prognosis. — A large proportion of cases terminate fatally 
if left alone. Aneurysms of the aorta are almost certainly 
fatal. The great danger lies in rupture ; pressure on sur- 
rounding viscera ; inflammation ;. and gangrene. 

Treatment. — Constitutional. — In those cases where surgical 
interference is contraindicated the patient must pass most of 
his time in a recumbent position ; avoid all excitement, exer- 
cise, or anything that would increase arterial tension. Give 
a minimum of liquids, and enforce a dry diet to reduce the 
quantity of blood and increase its richness. Over-activity of 
the circulation must be reduced by aconite or veratrum. Re- 
lieve pain by bromides, chloral, paraldehyde, or, as a last re- 
sort, opium. Constant administration of potassii iodidum in 
large doses (gr. xl-c, daily) favors formation of coagula. Ice 
or counter-irritation may relieve pain. Ergot is of doubtful 
utility. Tonic treatment if indicated. 

Local Treatment. — This includes all surgical means, such as 
ligation ; section of the sac ; introduction of foreign bodies ; 
electrolysis ; and such measures as come under the domain of 
surgical works. 

PHLEBITIS. 

Description. — Inflammation of the walls of a vein is caused 
by mechanical injury — compression, puncture, incision, or 
bruising. Due to syphilis ; gout ; extension from other parts ; 
high fevers ; varicosities ; cold. May be idiopathic. Phlebitis 
extends from its point of origin toward the heart. The super- 
ficial veins, when affected, stand out as hard cords ; are very 
tender to pressure ; outlined by a red line over their course. 



DISEASES OF THE CIRCULATORY SYSTEM. 145 

Surrounding tissues swollen. Constitutional symptoms are 
those of a septic fever : chills and rigors ; great anxiety ; hec- 
tic flush ; depressing sweats ; high temperature and increased 
pulse-rate. Thrombi form in the vein, are often carried into 
the general circulation, and cause septic thrombosis or embo- 
lism. Abscesses may form in the course of the vein. 

Treatment. — Absolute rest in bed and avoidance of nibbing 
or friction to prevent septic thrombosis or embolism. When 
the parts are swollen greatly, incise freely along the long axis 
of the vein. Hot applications often greatly relieve. Quinine 
should be administered in doses of gr. iij-xv, as indicated. 
Best nutritious diet and iron tonics. Abscesses must be 
promptly evacuated. 

DISEASES OF THE BLOOD. 

INTRODUCTION. 

The blood is an organized, vitalized tissue by which nutri- 
tion is supplied to every living cell of the body, and is kept in 
circulation through the arteries, arterioles, capillaries, venules, 
and veins, by the pump-like action of the heart and the resil- 
iency of the vessel- walls. Healthy blood consists of a color- 
less plasma in which the corpuscles are suspended, and is 
composed of twenty-one percent, of solid matter and seventy- 
nine percent, of water. The amount of blood in a healthy 
person is estimated at seven and seven-tenths percent, of the 
body- weight. The colorless plasma contains fibrinogen, albu- 
min, salts, and water. There are two kinds of blood-corpus- 
cles, the white and the red. The red corpuscles are round, 
biconcave disks, 3-5*00 inch in diameter, and number about 
five million to the cubic millimeter of blood. They convey 
oxygen from the lungs to the tissues, and carbon dioxide from 



146 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

the tissues to the lungs, where it is eliminated. The red cells 
are rich in haemoglobin, which seems to be the element in 
their structure that conveys the oxygen. The white corpuscles 
are irregular in structure and have an amoeboid movement. 
Their proportion to the red varies according to the diet, time 
of day, and general nervous condition. There is about one 
white corpuscle to one hundred red. Authorities differ in re- 
gard to the proportion and state it to be one white to fifty or 
three hundred red. The white cells act as scavengers and 
enter into every process of repair. 

ANLEMIA. 

Definition. — Anaemia is a general term used to designate a 
deficiency of the normal physiological elements of the blood, 
whether of mild or malignant type, and is always secondary to 
some pathological or mechanical disturbance. It is classified 
as (1) symptomatic or (2) essential. 

(1) Symptomatic Anaemia. 

Definition. — Symptomatic or secondary anaemia is that 
form in which the normal physiological constituents of the 
blood are diminished by mechanical causes or demonstrable 
pathological lesions. 

Etiology. — Most common in young girls and those of seden- 
tary habits. Every form of hemorrhage, primary or secondary, 
independent of causation. Improper diet. Mal-assimilation 
of food due to impaired digestion and bolting of food with- 
out proper ensalivation ; gastritis ; and structural lesions of the 
oesophagus, stomach, intestines, or liver. All chronic and acute 
diseases are attended by a certain amount of anaemia. Chronic 
discharges from abscesses, and sinuses, uterine disease, and 



DISEASES OP THE CIRCULATORY SYSTEM. 147 

allied troubles always diminish the nutritive power of the 
blood. Cancer, malaria, syphilis, tuberculosis, mineral and 
vegetable poisons, diseases of the lymphatic glands and the 
blood-making organs. Confinement in close rooms ; lack of 
exercise and pure, fresh air ; mental and physical over- work. 
Appears to be hereditary in some families. 

Symptoms. — Among the earliest symptoms of this condi- 
tion is pallor. The skin gradually loses its normal red or 
pink-tinged color and becomes pale and white. The mucous 
membranes assume an ashy-white or dull-white appearance. 
The conjunctivae look pearly- white. In fact the patient as- 
sumes a very " delicate " appearance. Slight exercise or ex- 
ertion causes shortness of breath, marked fatigue, palpitation 
of the heart, or exhaustion. Dizziness or syncope is produced 
by suddenly rising from a sitting or stooping posture to the 
erect. Tinnitus aurium ; pulse is weak and slightly increased ; 
constipation ; appetite is capricious and poor. These patients 
usually dislike fats, meats, and albuminoid foods, and prefer 
the improper diet of starches, "tea and toast," and coffee. 
Headache, vomiting, gastritis, loss of weight, and, late, dropsy. 
In profound anaemia functional murmurs are heard during 
systole at one or more valves of the heart, of a soft, blowing 
character. A bruit de diable or venous hum is heard over 
the lower portion of the jugular vein. Among the ultimate 
sequelae are gastritis, gastric ulcer, fatty degeneration of the 
heart and liver, chronic dropsy, and cerebral disorders. 

Pathology. — Whether dependent upon the rapid loss of 
blood from profuse hemorrhage or upon the slow drain of 
chronic disorders, the principle involved in secondary anaemia 
is always the same — the withdrawal of the albuminoid con- 
stituents and the red cells in large or small amounts. The 
constant drain on the blood cannot be met by the process of 
absorption, assimilation, and conversion of food into nutri- 



148 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

merit; hence a depravity of this tissue. The circulation of 
poisonous elements in the blood prevents the normal meta- 
bolic changes and impairs the process of absorption and 
assimilation. Impoverished blood means a change of a de- 
structive nature in the metabolic process (catabolism). Ex- 
amination of the blood with the microscope shows it to be 
thin j a marked absence of the normal rouleaux ; marked 
diminution in the number of red corpuscles. The white cor- 
puscles are unchanged. Haemoglobin is diminished in quan- 
tity. The tissues of the body show a lack of blood. The 
clots formed are not firm. 

Diagnosis. — Made from the general symptoms, microscop- 
ical examination of the blood, and clinical history. 

Prognosis. — Depends upon the cause. Most cases are re- 
mediable if not permitted to run until marked complications 
exist. 

Treatment. — Causal. — Seek for the cause and use means 

■ r 

toward its removal, for if allowed to remain your results will 
only be palliative or nil. 

Hygienic. — Insist upon daily exercise in the pure, fresh air 
of the country, mountains, or sea-shore. Live ont-doors as 
much as possible. Avoid close, stuffy rooms, close confine- 
ment, violent exercise, and excitement. Change occupation 
if necessary. Wear soft, light, medium- weight woolen under- 
clothing (always use pure-white woolen goods) during the 
whole year, and change outer garments according to tem- 
perature. This method of clothing one's self prevents sudden 
changes of bodily temperature and liability to take cold. 
Sleep in a cold room, with sufficient clothing to keep warm. 
Heated, unventilated, closed rooms are an abomination, and 
only add to the diseased condition. A daily, tepid, salt-water 
bath, followed by a brisk rub with a coarse towel, and rest 
for an hour or two afterward. Long hours of sleep at night. 



DISEASES OF THE CIRCULATORY SYSTEM. 149 

Dietetic. — Avoid coffee, tea, toast, large amounts of starchy 
foods, heavier vegetables, and those things that cause oppres- 
sion and indigestion. Encourage the use of hot, rich milk j 
soft-boiled eggs ; scraped beef, broiled over the coals and sea- 
soned to taste ; rich broths and soups ; pig's-feet jelly ; fish, 
occasionally ; game of any kind ; sweetbreads ; light custards 
and puddings ; baked potatoes. Insist on thorough mastica- 
tion and full time for each meal, with the avoidance of liquids 
to moisten and wash down the food. Take everything in 
moderation, as over-eating is productive of harm. Rest in the 
reclining position for an hour or longer after each meal. 

Medicinal. — Do not fall into the error that " ana?mia always 
indicates the administration of iron and arsenic." Symptom- 
atic anaemia per se requires very little medicine, but marked 
attention to the cause, diet, and hygiene. Meet every indica- 
tion with appropriate remedies. Stimulate the emunctories. 
Cod-liver oil may. be administered to advantage in some cases, 
if the digestion is not impaired by it. Iron is best given as 
an albuminate, and the following is a favorite combination of 
the author : 

Pulv. ferri albuminatis gr. ij. 

Strychninee sulphatis. 

Acidi arseniosi aa. gr. 1/60. 

Misce. Fiat in tablet (triturate). No. 1. Signa. One after 
meals and at bedtime. 

The elixir of the four chlorides is frequently administered 
with the best results, and consists of hydrargyri bichlo- 
ridum, liq. arsenici chloridi, tr. ferri chloridi, and acidum 
hydrochloricum. Many other combinations of iron are recom- 
mended, but with these two every indication can be met. 
Glycerole phosphates comp., f 3 j, after meals, is very efficient 
in many cases. 



150 a synopsis of the practice of medicine. 

(2) Essential Anemia. 

Essential or primary anaemia embraces those cases of pro- 
found anaemia whose pathology is not definitely known, and 
manifests itself in two principal forms, viz. : (a) chlorosis and 
(b) progressive, pernicious anaemia. 

(a) Chlorosis. 

Description — A profound variety of anaemia existing in 
females about the age of puberty. All the symptoms of sec- 
ondary anaemia are present, with the addition of a marked 
decrease or absence of the menstrual now, and hysterical mani- 
festations. The skin is changed to a white, waxy-like appear- 
ance in light-colored complexions, and ashy-white in dark- 
colored persons. Sometimes the skin presents a light tinge 
of green ; hence the name greensickness. The red blood-cor- 
puscles are diminished about fifty percent., and the haemo- 
globin is about twenty-five percent, of the normal. The red 
cells are more or less deformed. The pathology of this affec- 
tion is not definitely known, but the prominent theory appears 
to make it depend upon the non-ehmination of poisonous 
matters from the blood, and the presence in the circulation 
of ptomaines and leucomaines. This is possible, but rather 
improbable. 

Diagnosis. — In the negro race : young negro females ; 
eyes pearly- white ; dark areola below the eyes ; a peculiar ashy 
appearance of the skin, with a lack of the normal luster ; ex- 
treme pallor of all the mucous membranes ; and microscopical 
blood-changes, together with general symptoms already enu- 
merated. 

Prognosis. — Rarely fatal if treated early. It tends to recur 
after recovery. May last from a few months to many years. 
Complications are usually bad. 



DISEASES OF THE CIRCULATORY SYSTEM. 151 

Treatment. — Follow the same line of treatment indicated 
for symptomatic anaemia. 

(&) Progressive, Pernicious Ancemia. 

Synonyms. — Idiopathic anaemia ; malignant anaemia. 

Description. — A progressive, obstinate anaemia/common to 
both sexes between the twentieth and fortieth years, that ulti- 
mately tends to terminate fatally. Its causation is still ob- 
scure. Many theories have been advanced, but it is a question 
whether lesions of the stomach, bones, marrow, and spleen 
are not results rather than causes of the trouble. There are 
present all the symptoms of simple anaemia, greatly aggra- 
vated. Fever, varying from 100° to 103° F., is present at 
irregular intervals. Skin is pale and waxy-looking, with here 
and there large and small petechial spots. Diarrhoea is fre- 
quently obstinate. Retinal hemorrhages ; epistaxis ; and oede- 
ma of the ankles. Blood, examined microscopically, shows a 
great diminution of red cells. White cells normal. Red cells 
are pale, owing to a loss of haemoglobin, and distorted in 
appearance. Fatty degeneration of the heart, liver, and kid- 
neys complicates. The bone-marrow is reddened and contains 
nucleated red blood-cells. Iron pigment is deposited in the 
spleen, liver, and skin. Death at the end of one year is the 
usual termination. Recovery is rare. 

Treatment. — Treat as indicated in secondary anaemia. 
Meet symptoms and complications as indicated in each case. 

LEUCAEMIA. 

Description. — Leucaemia (leucocythaemia) is a pathological 
state of the blood in which there is a great increase in the 
number of white corpuscles, and accompanied by changes in 



152 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

the spleen (leucaemia splenica), marrow of the bones (leucae- 
mia myelogenica), and lymphatic glands (leucaemia lymphatica). 
This disease occurs most frequently in men about the fortieth 
year. Gradual enlargement of the spleen until dullness occu- 
pies the whole left side of the abdomen. Spleen is hard on 
palpation, with a sharp anterior border. Lymphatic glands 
of the neck, axilla, and groin are frequently enlarged. Liver 
may be increased in size. Soreness or tenderness on percus- 
sion often manifests itself in the long bones. Patient soon 
becomes anaemic in appearance. Dyspnoea 5 spontaneous hem- 
orrhage from the mucous membranes ; retinal hemorrhages. 
Temperature is slightly elevated, with occasional high fever 
or remissions. Ascites, obstinate diarrhoea, pleurisy, pneu- 
monia, and cerebral apoplexy complicate during the later 
stages. 

The blood is thin and pale 5 forms large, pale, soft, imper- 
fect clots. Haemoglobin and red cells are diminished in num- 
ber. White corpuscles are increased in number (one to six or 
even one to three), vary in size, and often multinucleated. The 
pathology of this disease is unknown. Prognosis is always 
bad. With few exceptions, death ensues within three years. 

Diagnosis. — Leucocytosis is a transient, temporary increase 
of the white corpuscles, without structural changes in the 
spleen, glands, or marrow of the bones, and never fatal. 

Treatment. — Symptomatic. — Treat as indicated in simple 
anaemia. Arsenic, iron, mercury, and gold seem to be the 
most efficient palliative remedies. Endeavor to reduce the 
enlarged spleen by cold douches aud inunctions of ung. hy- 
drargyri rubri (U. S. P.). 

PSEUDO-LEUCAEMIA. 

Synonyms. — Lympho-sarcoma ; Hodgkin's disease. 
Description. — A general enlargement of the lymphatic 



DISEASES OF THE CIRCULATORY SYSTEM. 153 

glands, accompanied by marked anaemia, cachexia, weakness, 
palpitation of the heart, dyspnoea, hemorrhages from the mu- 
cous membranes, dropsy, and, ultimately, death. Lymphoid 
growths appear in different parts of the body. Temperature 
is always high in the evening. Spleen and liver are enlarged, 
tender, and contain the lymphoid growths. The red blood- 
cells are diminished in number, but the white are unchanged, 
except an occasional increase in the later stages. 

Diagnosis. — At first it is uncertain, but the appearance of 
lymphoid growths makes it certain when taken with other 
symptoms. 

Prognosis. — Most cases terminate fatally. Some may be 
arrested temporarily. 

Treatment. — Best hygiene and diet, as in anaemia. Iron, 
cod-liver oil, syrup of hydriodic acid, and arsenic in the early 
stages. Later, use mercury, the iodides, and chloride of gold. 
Treat symptomatically. 

SAPR^MIA. 

Definition. — Sapraemia (ca-npog, putrid ; aifia, blood) is a fe- 
brile reaction dependent upon the absorption and circulation 
of ptomaines (a product developed by germs) in the blood. 

Etiology. — Ptomaines are absorbed and carried into the 
circulation from putrefying or improperly cleansed wounds, 
sores, or sinuses ; the development of germs in the intestinal 
canal in typhoid and typhus fevers; obstinate constipation; 
and cancers. In fact, ptomaines are developed in some por- 
tion of the body in every cisease, are absorbed, and cause vary- 
ing degrees of sapraemia. 

Symptoms. — Frequently begins with a chill, followed by 
fever. Other cases begin with slight headache ; tendency to 
vertigo ; general malaise ; occasional nausea or vomiting ; in- 



154 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

creased pulse-rate ; gentle or profuse perspiration. Temper- 
ature gradually rises to 101° or 103° F. If the cause is not 
removed delirium sets in, and the trouble soon passes from a 
state of sapraemia to one of septicaemia or pyaemia. 

Pathology. — The condition is dependent entirely upon the 
absorption of ptomaines, not germs. Every germ, by its 
growth and development, excretes a product recognized by 
us as a ptomaine. This ptomaine acts as an irritant, when 
coming from certain germs, and when taken into the circu- 
lation is brought in contact with the various nerve-centers, 
over-stimulates them, and causes the symptoms mentioned. 
The severity of the affection varies with the amount and 
character of the ptomaine absorbed. 

Prognosis. — Usually very good, provided the seat of 
trouble can be reached with appropriate remedies. The 
greatest dangers lie in the production of profound anaemia 
in prolonged cases, exhaustion, heart-weakness, septicaemia, 
and pyaemia. 

Treatment. — Remove the cause. Thoroughly cleanse cuts, 
burns, sinuses, abscesses, and all surgical wounds with anti- 
septic solutions, and the trouble will remedy itself. When 
dependent upon deleterious products in the intestinal canal, 
administer purgatives and intestinal antiseptics. If the pto- 
maines can be neutralized by antiseptics the symptoms sub- 
side at once. No known drug will render the blood antiseptic. 
Sustain strength with stimulants, quinine, and iron. Treat 
causative trouble. 

SEPTICAEMIA. 

Definition. — Septicaemia (oijttg), to putrefy; ai\ia y blood), 
" blood-poisoning," is an acute, infectious disease caused by 
the presence of disease germs and their ptomaines in the cir- 
culation, and is never complicated by multiple abscesses. 



DISEASES OF THE CIRCULATORY SYSTEM. 155 

Etiology. — Disease germs enter the blood from surgical 
wounds ; bites of animals, reptiles, and insects ; dissecting 
wounds ; post-partum troubles ; breathing septic gases ; acute 
infectious and contagious diseases ; and the absorption of sep- 
tic matter. 

Symptoms. — Frequent rigors, followed by fever, 101° to 
105° F. ; exhausting sweats ; delirium or coma ; rapid pulse ; 
enlarged and tender spleen ; headache ; nausea and vomiting ; 
hemorrhages from the internal organs ; petechial spots on the 
skin ; loss of function of one or more parts of the body. Blood 
is impoverished and contains an increased number of white 
blood-corpuscles and a diminished number of red. Germs 
are also found in the blood. Secondary abscesses never form 
in simple septicaemia. Convalescence is slow. The disease 
assumes a typhoid state. Embolism, endocarditis, and pyaemia 
often complicate. 

Prognosis. — Depends upon the cause. Embolism and pyae- 
mia, as complications, are bad signs. 

Treatment. — All surgical and medical causes should be 
dealt with from the antiseptic standpoint and operative pro- 
cedure. Quininae bisulphas, gr. ij, every two hours, with 
tr. ferri cliloridi, gtt. v. Salicylate of soda or ammonia will 
relieve fever, and is antiseptic. Sulphocarbolate of zinc, 
gr. ij-v, or salol, gr. v, every two or four hours, exerts an 
antiseptic influence, especially when the trouble has its origin 
in the intestinal canal. 

Sustain strength by stimulants and most nutritious diet at 
frequent intervals. "Administer alcoholic liquors freely," 
says one physician, "until you obtain their physiological 
effects, for these cannot be obtained until the disease is 
checked." Stimulate the emunctories. Stimulate during the 
whole period of convalescence, Treat all complications and 
sequelae. 



156 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



PYEMIA. 

Definition — Pyaemia is septicaemia accompanied by second- 
aiy, metastatic abscesses. 

Etiology. — The exciting canse is the presence of pyogenic 
germs, which enter the circulation through some abrasion. 
Surgical and dissecting wounds, ulcers, abscesses, sinuses, gon- 
orrhoea, Bright's disease, phlebitis, acute fevers, malignant 
endocarditis, and uterine diseases all predispose to this con- 
dition. Some cases appear to be idiopathic. 

Symptoms. — Begins suddenly with a chill, followed by high 
fever, profuse sweating, and marked prostration. Chills and 
rigors occur at intervals of several hours or days. Fever 
intermits and remits. Flushed face ; great thirst ; coated, dry 
tongue ; increased respiration ; rapid emaciation ; anaemia ; 
jaundice, occasionally ; nausea, vomiting, and diarrhoea. 

Secondary or metastatic abscesses soon form in different or- 
gans and parts of the body. The lungs seem to be the most 
frequent seat of abscesses. Septic, ulcerative endo- or pericar- 
ditis ; peritonitis ; abscesses of the liver and spleen. In chronic 
cases the joints and subcellular tissue of the skin are most 
commonly affected. When abscesses form, the disease as- 
sumes a typhoid condition and usually terminates fatally. 
Cerebral symptoms are prominent, and mask other signs in 
many cases. 

Pathology. — The disease is undoubtedly caused by the en- 
trance of a variety of the pyogenic germ (streptococcus pyo- 
genes albus ; s. p. aureus ; s. p. citreus), together with its pto- 
maines. Ptomaines cause the acute symptoms by their action 
upon the nerve-centers. 

1. The pyogenic germ enters the circulation direct; finds 
lodgment in some of the tissues of the body j develops at the 



DISEASES OP THE CIRCULATORY SYSTEM. 157 

expense of those tissues; causes inflammation, with breaking 
down of cell-structure and suppuration. Thrombi form, break 
up, and throw septic emboli into the general circulation. These 
And lodgment in the lungs, liver, spleen, or other organs, and 
produce new foci of suppuration. 

2. Small particles of septic matter, bearing the pyogenic 
germ, enter the circulation as septic emboli directly from ab- 
scesses, surgical wounds, or post-partum uterine troubles, and 
cause the disease. 

3. Some cases appear to arise idiopathically. In these cases 
the germ enters from some unknown source. 

Prognosis. — Recovery, although possible, is rather uncer- 
tain. Grave complications and sequelae always accompany 
and follow the disease. 

Treatment. — Preventive. — Never neglect surgical wounds, 
abscesses, ulcers, and post-partum affections, but treat them 
radically with the latest antiseptic precautions — always look- 
ing to free drainage. Keep the emunctories active, and the 
best physiological condition possible. Avoid the use of un- 
clean surgical instruments. Look to personal cleanliness. 
Destroy all septic products from the patient. 

Active Treatment. — Sodii salicylas, gr. v-x, every three 
hours, or sulphocarbolate of zinc, gr. j-v, every three hours, 
with a view to antisepsis. Accompany these remedies with 
quinina? bisulphas, gr. ij-v, at intervals of two or four hours. 
Stimulate freely with alcoholics, and most nutritious, concen- 
trated, liquid diet. Promptly evacuate and treat every abscess 
as soon as discovered, provided it can be reached. If neces- 
sary, reduce temperature by cold sponge-bath rather than 
resort to aconite, acetanilide, and other heart-depressants. 
Extreme caution must be exercised to prevent inoculation 
of the disease, as it is infectious and will reproduce itself 
in others. During convalescence administer best diet and 



158 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

tonics of iron, arsenic, strychnine, and quinine. Free exercise 
in open air. 

PURPURA. 

Description. — Purpura consists of hemorrhage into the 
upper layers of the skin, from disease or traumatism. Simple 
traumatic purpura is caused by bruises, and manifests itself 
as ecchymoses. Medically it is a condition manifesting itself 
as purpura simplex ; purpura hemorrhagica ; purpura rheu- 
matica ; purpura urticans. 

Purpura simplex manifests itself by the appearance of spots 
varying in color from a pale red to a blue or purple. These 
spots are from the size of a pin's head to one-half inch in 
diameter, not elevated, and not influenced by pressure. They 
appear on any portion of the bod}\ In a few days the color 
gradually changes to a blue, brown, or yellow tint, and finally 
the spots disappear. No constitutional symptoms, aside from 
slight anaemia, very mild fever, and loss of appetite. Simple 
cases recover in ten days or two weeks, but are liable to 
recur. 

Purpura hemorrhagica ("land-scurvy ") is an aggravated 
form of the simple trouble, accompanied by profuse hemor- 
rhage from the mucous membrane of the nose, mouth, bronchial 
tubes, stomach, intestines, kidneys, or from the serous mem- 
branes. Mucous membrane is not swollen or spongy. Anae- 
mia, with all its symptoms, complicates. 

Purpura rheumatica is an acute rheumatism in which blood 
is extravasated into the layers of the skin. 

Purpura urticans is a simple purpura complicated by urti- 
caria or simple hives. 

Pathology. — No definite pathological factor has been found 
to satisfactorily explain the affection. Among theories ad- 



DISEASES OF THE CIRCULATORY SYSTEM. 159 

vanced are : (1) localized lack of vaso-motor tone ; (2) disease 
of the capillary blood-vessels of the skin ; (3) a change in the 
character of the blood. 

Treatment. — Simple pnrpnra is relieved by rest in bed. 
Severe cases require tonics of iron, arsenic, and strychnine. 
Turpentine, ergot, tannic and gallic acids, in hemorrhages 
from the mucous membranes. Treat symptomatically and 
according to complications present. 

SCORBUTUS. 

Synonyms. — Scurvy ; sea-scurvy. 

Definition. — A form of purpura occurring among those 
who have been living on an innutritious diet, with a lack of 
vegetables and vegetable acids. 

Etiology. — Most common among sailors, soldiers, and con- 
victs, who cannot procure a diet of fresh vegetables and acids. 
A diet of salt pork is a common cause. Uncleanliness, expos- 
ure, intemperance, and other diseases predispose to an attack 
of scurvy where a proper diet is lacking. Northrup and 
Crandall describe infantile scurvy, which is often present where 
prepared foods and condensed milk are used exclusively. 

Symptoms — Onset is slow. Patient becomes pale, weak, 
indifferent to duty, drowsy, stupid, and has shooting pains in 
the back and legs. An eruption of purpura appears first on 
the legs, then on other parts of the body. The gums are 
swollen, spongy-like, separated from the teeth, covered with a 
white, offensive coating, bleed freely when touched, and often 
ulcerate. Teeth loosen and fall out. Tongue is coated, large, 
and flabby. Hemorrhages from all the mucous membranes, 
with slight elevation of temperature in the later stages. (Ede- 
ma of the lower extremities and enlargement of the spleen. 
Severe cases have ulcers of the skin, gangrene, pulmonic 



160 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

troubles, pleurisy, and obstinate dysentery. Healed ulcers, 
cuts, and fractures often break their line of union in the later 
stages. Death is caused by syncope, exhaustion, hemorrhage, 
or one of the complications. 

Pathology. — The disease is undoubtedly due to a lack of 
vegetable diet and the vegetable acids, and is neither infec- 
tious nor contagious. Why an absence of vegetables should 
produce a pathological condition of this kind is not known. 
It has been ascribed to a lack of the salts of potash, but these 
salts will not cure if given alone. There is a lack of vaso- 
motor tone. The blood is diminished in bulk, impoverished, 
and watery in consistence. Many of the tissues of the body 
are atrophied. Spleen is enlarged. 

Prognosis. — Very favorable, if not complicated. 

Treatment. — Preventive. — Scrupulous cleanliness of the body 
and of the apartments used. A liberal diet of fresh or dried 
vegetables and fruit, fresh milk, and beef -juice. Sailors, 
soldiers, and convicts, who cannot obtain fresh vegetables, 
should take not less than one ounce of lime or lemon juice 
daily. Stimulants used in moderation if necessary. 

Active Treatment. — Rest in bed. Medicinal treatment is of 
secondary importance in uncomplicated cases, as a change of 
diet to lime or lemon juice, tart fruits, vegetables, milk, and 
fresh beef will meet every indication. Washes of alum, chlo- 
rate of potash, capsicum, carbolic acid, and other astringents 
and antiseptics, for the condition of the gums. Treat all com- 
plications and sequelae as indicated in other parts of this work. 
Tonic treatment. 

HAEMOPHILIA. 

Description. — Haemophilia, hemorrhagic diathesis, bleeders' 
disease, is a tendency to obstinate hemorrhage, resulting from 



DISEASES OF THE CIRCULATORY SYSTEM. 161 

the slightest abrasion or occurring spontaneously. It is a 
congenital disease transmitted from mother to son, and rarely 
found in women. It may skip one generation and manifest 
itself among the male members of the next. Etiology is un- 
known. The disease usually manifests itself in the first few 
years of life by an obstinate, spontaneous hemorrhage from 
one of the mucous membranes, or an unusually large and 
obstinate hemorrhage from a slight surgical wound, which is 
so severe that it frequently cannot be controlled until the 
patient is almost exsanguine. These patients are in good 
health during the intervals, but are anseniic from the loss of 
blood. Blood often escapes into the joints or under the skin, 
forming large blood-tumors. Death during the early years of 
life is the common sequel, but some live to pass middle life. 

Treatment. — Best results can be accomplished by prophy- 
laxis. No operation, unless absolutely necessary, should be 
done upon one who is a haemophiliac. Keep the emunctories 
active. Avoid too rich diet and over-exertion. A sedentary 
life is best. Hemorrhage must be controlled by surgical and 
medical means. Always be prepared to meet secondary hem- 
orrhage. These classes of patients should never marry — this 
being the only manner of eradicating the disease. 



DISEASES OF THE SUPRABENAL CAPSULE. 



ADDISON'S DISEASE. 

Definition. — A disease, brought to the attention of the pro- 
fession by Thomas Addison in 1855, in which there is debility, 
feeble circulation, vomiting, pigmentation of the skin, and de- 
generation of the suprarenal capsule. Sometimes termed mal- 
asma suprarenale. 

Etiology. — Most common in males from eighteen to forty 
years of age. Tuberculosis, debility, and poverty appear to 
predispose. No definite or distinct cause can be mentioned 
yet. 

Symptoms. — Onset is gradual, with a constant feeling of 
languor, depression, and anaemia. Occasional pains in the 
back. Tendency to syncope. Heart's action is weak, and the 
pulse is compressible and small. Nausea and vomiting appear 
later, and often prove obstinate. The face and body assume 
a bronzed appearance in irregular patches, which eventually 
coalesce and cause a uniform dark color over the whole or a 
part of the body. Anaemia becomes profound. Dropsy is a 
late symptom. The disease may remit for a time, but soon 
returns. 

Pathology. — No positive origin can be given. Some claim 
it to be due to a tuberculous process involving the suprarenal 
capsule and surrounding glandular structure. If the supra- 
renal capsules are blood-making organs, degeneration and 
impairment of their function may account in part for the 

iC2 



DISEASES OP THE SUPRARENAL CAPSULE. 163 

anaemia. That there is an impairment of the vaso-motor 
supply of the skin is shown by the deposit of black coloring 
matter in the rete malpighii. The suprarenal capsules are 
enlarged, irregular, and vary in color from a gray to a green 
or yellow. Sometimes they are cheesy. Degeneration is 
either tuberculous or calcareous. Surrounding connective 
tissue is thickened, and the cicatricial tissue may press upon 
branches of the pneumogastric and solar plexus. Tuberculo- 
sis is frequently found in other organs. 

Prognosis. — Death terminates the disease within one year 
£,nd a half. Rarely, it may intermit and last several years. 

Treatment. — Nothing can be done to cure. Symptomatic 
treatment. Best diet, stimulants, tonics, and alteratives. 



DISEASES OF THE MOUTH. 



STOMATITIS. 

Synonyms. — Catarrh of the mouth ; simple or erythematous 
stomatitis ; inflammation of the mouth. 

Definition. — Stomatitis is an inflammation of the mucous 
membrane of the mouth, recognized by redness, heat, pain, 
exudation, and impaired function. 

Etiology. — Alcohol, hot liquids, tobacco ; sharp points and 
tartar on the teeth ; teething, improper food, mechanical or 
chemical injury, uncleanliaess, exposure to cold, and extension 
from other parts, as from erysipelas. It is secondary to measles, 
scarlet fever, variola, and disordered digestion. 

Symptoms. — Mucous membrane of the mouth is dry, hot, 
red, and swollen. There is a profuse flow of mucus. A 
burning sensation, and tenderness on pressure. Breath is bad, 
and there is a bitter, clammy taste in the mouth every morn- 
ing. Sense of taste is blunted; salivation not infrequent. 
Great thirst ; fever absent or very slight ; not usually accom- 
panied by indigestion. Infants cry, are restless, cannot 
properly grasp the nipple, and often refuse it entirely. 
Tongue is swollen, covered with a yellowish- white coating, 
and indented by the teeth. Acute stomatitis is most com- 
mon in children. 

Chronic stomatitis is most common in adults. Tongue is 
coated and flabby ; bitter taste in the mouth, and a desire for 
highly seasoned food ; marked depression of spirits j and sub- 
acute or chronic symptoms similar to the acute. 

1G4 



DISEASES OF THE MOUTH. 165 

Pathology. — Acute stomatitis is confined to the mucous and 
submucous tissues of the mouth and tongue. Secretion is at 
first lessenedjjihen increased, and acid in reaction. Pathology 
is that of a simple inflammation. In the chronic form, the 
papillae are more prominent ; inflammatory tissue is formed ; 
infiltration follows ; and the functions of the tongue and sali- 
vary glands are permanently impaired or lost. 

Diagnosis. — Direct examination and history suffice. 

Prognosis. — Good in acute cases. Short in duration. 
Chronic stomatitis depends upon the removal of the cause. 

Treatment. — Remove cause. Have sharp points and tartar 
on the teeth removed. Avoid all irritants such as condiments, 
spices, and tobacco. Cleanse the mouth frequently, espe- 
cially after eating, with borax-water, lime-water, or solution 
of carbonate of soda. Bichloride of mercury, gr. j-f Iviij, 
locally. y 

Acidi borici 3 iss. 

Glycerini f ? ss. 

Aquae q. s. ad. f 1 ij. 

M. Signa. Use freely as an application to the affected parts. 

Weak salt water ; a mixture of carbolic acid, glycerin, and 
tr. iodini comp. ; tr. myrrhae et capsici co., gtt. xv to a tum- 
bler of water, make good mouth- washes. General stimulants 
if necessary. Stimulate the emunctories. Listerine, or ext. 
pinus Canadensis fluid., and chlorate of potash are used as 
bases for mouth-washes. Salicylic acid, gr. j-f 1 j, applied 
locally, will relieve the burning pain. If the inflammation is 
severe in teething children, it is well to lance the gums. Chew- 
ing a piece of rhubarb-root before retiring is an old but effect- 
ive remedy. Solutions of sulphate of copper and zinc, in vary- 
ing strengths, are used. 



166 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



APHTHAE. 

Synonyms. — Aphthous, follicular, vesicular, or croupous 
stomatitis. 

Definition. — A circumscribed, croupous stomatitis, recog- 
nized by small, isolated, round, white vesicles which coalesce 
and develop upon or under the epithelial layer of the mucous 
membrane, break, and leave an open ulcer which is very slow 
to heal. 

Etiology. — Teething and bad hygiene are the most prolific 
causes. Common among the poor and those reduced by 
disease. Epidemic and probably contagious. Complicates 
measles, diphtheria, and other diseases of the mouth. 

Symptoms. — Rise of temperature ; tongue is sore, and the 
child nurses with difficulty ; vomiting and great thirst ; breath 
smells sour ; diarrhoea. The mucous membrane of the mouth 
is covered in places with a number of aphtha?, or small, pearly 
vesicles as large as a millet-seed, either isolated (discrete) or 
running together (confluent). These a.phtha3 break, and leave 
an ulcer which has a frosty appearance and hard, thickened 
edges. It appears first on the lower lip, and spreads. When 
confluent, symptoms are aggravated and child refuses to nurse. 
These ulcers heal very slowly. 

Diagnosis. — Made from the pearly- white vesicles and frosted 
ulcer with thickened edges. 

Prognosis. — Very good, if taken early. 

Treatment. — Hygienic. — Fresh air, proper clothing, and 
cleanliness of body. Regulate diet according to the indications 
of the case. In young, nursing children, cleanse the mouth 
with a soft rag and a solution of borax, glycerin, and water 
after each feeding. Solutions of salt, chlorate of potash, or 
antiseptics may be used. Internally, give a free purge of calo- 



DISEASES OF THE MOUTH. 167 

mel, or rhubarb and soda, to remove deleterious products in 
the stomach and intestines, to be followed by five grains of 
potassii chloras, three times daily. Give tonics if indicated. 
Touch the ulcers with tr. ferri chloridi, agrenti nitras, or 
the mitigated stick, and apply either aristol, europhen, pyoc- 
tanin, iodoform, or bismuth. Ext. hydrastis fluidi, applied 
locally, is useful. 

CANCRUM ORIS. 

Synonyms. — Diphtheria of the mouth ; ulcerative stomati- 
tis 5 gingivitis ulcerosa. 

Definition. — An acute diphtheritic exudation, limited at 
first, which spreads, exfoliates, and leaves an angry, ulcerated 
sore with deep sides, and infiltration of the surrounding tissues. 

Etiology. — Occurs in children from five to ten years of age. 
Bad hygiene and poor diet ; debility and weakness from dis- 
ease ; epidemic at times ; mercurialism ; embolism • contagious. 

Symptoms. — Pain, aggravated by mastication j salivation ; 
thick coating on the gums and teeth ; caries and necrosis of 
maxillary bones ; breath very offensive ; gums red, swollen, 
and tender. Parotid glands are swollen and painful. Saliva 
is bloody, digestion disordered, and diarrhoea j fever, restless- 
ness, and insomnia. Submaxillary glands are enlarged and 
tender. Entero-colitis often complicates. 

Pathology. — Gums are congested, swollen, and separated 
from the teeth. An exudation appears which is thick, white, 
yellow, gray, or black, and cuts off the blood-supply, causing 
localized gangrene. Sloughing ensues, and an ulcer results 
which is irregular, with raised edges, not deep, and covered 
with a yellow exudation. It extends to the inside of the cheek 
and tongue, and may cause necrosis of the maxillary bone. 
Undoubtedly dependent on a germ. 



168 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Diagnosis — Noma has an ulcer which is not hard, tense, 
shiny, or hollowed out; less constitutional disturbance and 
slower in its course. 

Prognosis. — Good. Not usually fatal if properly treated. 
Ulcers heal by cicatrix. Some teeth are invariably lost. 

Treatment. — Bear in mind the cause. Diet must be most 
nutritious. Egg-nog, wine, brandy, beef-pulp, beef-extracts, 
milk, and cream. Internally, give potassii chloras, gr. xx per 
day. An adult may take as much as forty grains of potassii 
chloras in one day ; it appears to exert an action almost spe- 
cific. Quinine, iron, and stimulants may be used. 

Potassii chloratis 3 ss. 

Syr. ferri, quininee et strychninse phos. f 3 v. 

Elix. aurantii q. s. ad. f I ij. 

M. Signa. One teaspoonful every four hours to a child six 
years old. 

Locally, use washes of hydrogen peroxide, borax, or potassii 
chloras ; touch ulcers with silver nitrate or dilute hydrochloric 
acid. Tanner uses zinc or chlorinated soda, one dram to a 
cup of water, as a mouth-wash. May apply sulphate of cop- 
per, nitric acid, or acid nitrate of mercury. Cover the ulcer 
with dried alum, bismuth, aristol, europhen, or iodoform. 
Cleanliness is the great feature, especially after eating. Under- 
wood uses a decoction of cinchona with dilute sulphuric acid. 
" No local treatment will succeed if general measures are neg- 
lected." (E. Smith.) 

ULCERS OF THE MOUTH. 

An ulcer is a solution of continuity of the soft parts. There 
are nine distinct classes of ulcers of the mouth, viz. : (1) a 



DISEASES OF THE MOUTH. 169 

vesicular sore spot on the tongue ; (2) diffuse catarrhal, with 
much pain and salivation ; (3) follicular, due to the occlusion 
of a gland or vicarious menstruation — sometimes mistaken 
for chancre ; (4) angular, at the angles of the mouth ; (5) her- 
petical, due to herpes ; (6) ulcers on the roof of the month, 
due to variola; (7) ulcers of the tongue, caused by sharp 
teeth; (8) syphilitic; (9) scorbutic. 

Diagnosis. — Determined from history of the case. 

Prognosis. — Depends entirely upon the class. 

Treatment. — Avoid hot food, tobacco, and irritants in all 
cases. Catarrhal ulcers should be cleansed with peroxide of 
hydrogen or bichloride of mercury, gr. ss-Oss. Follicular 
ulcers should be painted with a solution of silver nitrate, and 
then dusted with aristol, iodoform, or boric acid. In angular 
ulcers, touch with pure acetic acid and apply adhesive straps 
over the corners of the mouth to prevent irritation and pain 
in opening it. Borax and glycerin (one to ten) ; resorcin and 
glycerin (one to ten). Aristol and europhen make good ap- 
plications. Syphilitic ulcers are derived from kissing, towels, 
pipes, and cigars which have been used by syphilitic patients, 
and must be treated specifically with mercury or other altera- 
tives. Other ulcers are treated according to cause. 

THRUSH. 

Synonyms. — Parasitic stomatitis ; " white mouth " ; sprew j 
muguet. 

Definition. — Thrush is a parasitic disorder, due to a fungus 
which attaches itself to the mucous membrane of the mouth 
or pharynx, and causes stomatitis and gastro-intestinal disor- 
ders. Thrush is a symptom, and indicates a pathological con- 
dition of the system. 

Etiology. — Caused by the oidium albicans, which is similar 



170 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

to the oidium lactis. Uncleanliness, dryness, and acidity of 
the buccal secretions favor it. Most common in summer 
among bottle-fed children. Imperfect ventilation, sanitation, 
and crowding favor its development. It is rare in nursing 
children. Not directly contagious ; may occur in adults who 
are debilitated by cancer or tuberculosis. 

Symptoms. — Pain, aggravated by nursing or mastication ; 
lips are swollen ; saliva increased ; breath hot and bad ; 
some fever. Diarrhoea of a sour, green, and irritating char- 
acter. Gams and mucous membrane are covered with a white, 
curdy exudation, which, when removed, shows a white, frosty 
ulcer. Nausea and vomiting. 

Pathology. — Microscopical examination of the buccal secre- 
tions shows the presence of the oidium albicans. The exuda- 
tion is composed of fat-globules, epithelium, filaments, and 
spores. Exudation begins at the angles of the mouth and 
extends posteriorly. 

Diagnosis. — Diphtheria spreads from below upward ; thrush 
spreads downward and backward. Diphtheritic membrane is 
adherent. Aphthae has a deeper ulcer, is more isolated, and 
occurs later in life. 

Prognosis. — Good, if taken before bowel- complications are 
pronounced. 

Treatment. — Cleanliness of the mouth and body. Nurs- 
ing-bottles must be thoroughly cleansed, as well as the nipple. 
Improve hygiene ; keep the child in the fresh air, and place 
a flannel belly-band around its abdomen. Cleanse the mouth 
with solutions of hydrogen peroxide, borax, glycerin, or lime- 
water, after feeding. Acidum salicylicum or sodii bromidum 
(oue to eight), locally. Touch superficial ulcers with zinc 
sulphate, gr. x-f § j. 

Regulate diet. Sterilize milk and add lime-water to it. 
Artificial foods may be indicated. For irritable stomach, give 



DISEASES OF THE MOUTH. 171 

small doses of calomel or bismuth. Treat diarrhoea with syr. 
rhei aromatici, calomel, salol, or sulphocarbolate of zinc, and 
lactopepsin. 

GLOSSITIS. 

Synonyms. — Inflammation of the tongue ; psoriasis of the 
tongue ; glossitis desiccans. 

Definition. — Glossitis is an inflammation of the parenchym- 
atous structure of the tongue, recognized by swelling, pain, 
and general inflammatory symptoms. 

Etiology. — Acute glossitis is due to burns, stings of insects, 
scalds, chemicals, or traumatism. It attends erysipelas, pyae- 
mia, and variola. Psoriasis of the tongue is clue to syphilis. 
Chronic glossitis depends upon local irritants, such as points 
and tartar on the teeth, and the use of tobacco. 

Symptoms. — Tongue is dark red, swollen, painful, and may 
protrude from the mouth. Great pain in mastication, swal- 
lowing, and talking. Often impossible to swallow or speak. 
Salivation, and enlargement of cervical and submaxillary 
glands. Asphyxia may result from swelling. Abscesses may 
form. Pulse is rapid • fever and restlessness. All symptoms 
increase when abscess forms. In glossitis desiccans the surface 
of the tongue is fissured and lobulated, and the fissures are 
filled with food and debris. Psoriasis of the tongue presents 
a hard, cracked, varnished, or shiny appearance. 

Pathology. — Acute Glossitis. — An inflammation of the par- 
enchymatous structure of the tongue, with an exudation of 
serum and leucocytes into it. Resolution may be prompt, or 
pyogenic germs may complicate and produce suppuration. A 
thick, white or gray exudation of epithelium, mucus, germs, 
food, and filaments covers the tongue. Cicatrices or perma- 
nent thickening may remain. Chronic glossitis is confined to 



172 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

the edges of the tongue, with redness, thickening, and hyper- 
trophied patches. 

Diagnosis. — Amite glossitis is readily diagnosed from symp- 
toms given. Chronic glossitis may be mistaken for cancer, 
but the latter is much more rapid and painful, with marked 
cachexia. 

Prognosis. — Acute glossitis lasts about one week and termi- 
nates in resolution or suppuration. Chronic glossitis rarely 
makes complete recovery. Glossitis occurring in the course 
of a fever is unfavorable. 

Treatment. — Acute Glossitis. — Administer small doses of 
aconite, veratrum, acetanilide, or phenacetin, for fever. For 
swelling and pain, apply cold or hot washes constantly. Ice 
can be used freely. Scarification of the tongue should be deep. 
Calcium sulphide may prevent suppuration. When abscess is 
diagnosed, open freely and cleanse with hydrogen peroxide. 
Tonics and stimulating diet must be pushed. Impending 
suffocation demands free incisions in the tongue or trache- 
otomy. 

Chronic Glossitis. — Remove cause; touch edges of tongue 
with silver nitrate. Solutions of tr. opii, cocaine (four per- 
cent.), or leeches will relieve congestion and pain. The use of 
depressants must be guarded. Jaborandi and pilocarpine are 
better than quinine and may abort acute attacks. Glossitis 
desiccans is mitigated by applications of silver nitrate, but 
rarely cured. Psoriasis of the tongue requires specific treat- 
ment, as in syphilis, and local applications of carbolic acid. 

NOMA. 

Synonym. — Gangrene of the mouth. 

Etiology. — Most common in cachectic children and con- 
valescents from measles, scarlatina, variola, pertussis, cancrum 



DISEASES OF THE MOUTH. 173 

oris, tuberculosis, and debilitating disorders. Most common in 
girls from two to twelve years of age. Embolism and throm- 
bosis. Not contagious. 

Symptoms. — Commences in the cheek as a small vesicle 
which is filled with serum. It soon becomes black and sloughs 
until half the cheek and gums may be involved. Teeth drop 
out, and necrosis of the maxilla follows. Glands of the neck 
and submaxillary region are tender and swollen. Cheek is 
swollen, hot, and tender. There is little or no pain at first, 
and the child may pass the early stages without complaining. 
A hard nucleus can be felt in the cheek j breath is very offen- 
sive, and saliva bloody and thick. Diarrhoea is present ; great 
thirst, debility, and emaciation. 

Pathology. — Circulation to the part is cut off; nutrition 
ceases, and necrosis follows. When sloughing begins there 
is a secondary infection with germs, producing greater activ- 
ity, offensive discharges, and increased phagedena. The pri- 
mary lesion is a small vesicle which gets dark, sloughs, and 
leaves a malignant ulcer (phagedenic ulcer) which spreads to 
the surrounding tissues and causes destruction of the whole 
cheek and maxillary bone. 

Diagnosis — History, age, cachexia, debility, and rapidity 
of its course. 

Prognosis. — Depends upon constitution of patient, cause, 
and means used to cure it. Most common termination is 
death. 

Treatment. — Actual cautery, at the onset, with fuming nitric 
acid, galvano-cautery, hot iron, or any acid. Rich, concen- 
trated, stimulating, albuminous diet. Free use of stimulants. 
Remove sloughs at once and treat with hydrogen peroxide, 
potassium chlorate, aristol, europhen, pyoctanin, iodoform, 
or burnt alum. Feed per rectum or by stomach-tube. 



174 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



HEMORRHAGE FROM THE MOUTH. 

Description. — Hemorrhage from the mouth is a flow of 
blood, venous, arterial, or capillary, from any of its tissues, 
and is a symptom of some pathological condition. It is due 
to mechanical or chemical injuries ; plethora, haemophilia, or 
scurvy j from the socket of a tooth ; ulcers ; varicose veins ; or 
erosions from cancer. May be dependent upon a vicarious 
menstruation. Symptoms are those of hemorrhage. Diagno- 
sis is made by direct examination of the mouth, and fatality 
will depend upon the cause. 

Treatment. — If arterial, ligation may be demanded. Tor- 
sion and compression are effectual in many cases. Other 
hemorrhage is checked by Monsel's solution, alum, tannic acid, 
or other astringents. A four-percent, solution of cocaine 
stopped it in one case. If from the socket of a tooth, pack it 
with tannic acid. Actual cautery with the hot iron is an old 
and well-tried remedy. If there is great loss of blood and 
syncope, lower the head, give stimulants, and resort to trans- 
fusion of a saline solution or blood, if necessary. Grive hot 
drinks internally to increase the bulk of blood. The excit- 
ing cause must always be removed if possible. Treat symp- 
tomatically. 

CANCER IN THE MOUTH. 

Description. — Cancer in the mouth may involve the mu- 
cous membrane lining the lips, gums, hard and soft palate, 
floor of the mouth, or tongue. Most common form is epithe- 
lioma. Mostly found on lower lip or tongue. History of a 
boring and shooting pain, accompanied later by cachexia, sali- 
vation, and formation of a cancerous ulcer. Cachexia appears 



DISEASES OF THE MOUTH. 175 

early, and the disease runs a rapid course. Diagnosis is easy 
and prognosis is bad. 

Treatment. — Excision, if done early, is sometimes effectual. 
The whole tongue may be removed. Some authors recom- 
mend division of the gustatory nerve to relieve pain. In epi- 
thelioma no application is better than powdered potassium 
chlorate or aristol. Cures have been reported by this means, 
but are questionable. Inoculation of cancer with the germ of 
erysipelas is said to have cured some cases in Germany, but 
this remains to be confirmed. Best diet and stimulants. Put 
off the use of opium until the last, when it is most needed to 
give relief. Applications of jequirity are highly recommended. 



PTYALISM. 

Synonyms. — Salivation ; mercurialism. 

Definition. — Ptyalism is a symptom and not a disease, char- 
acterized by increased flow of saliva, bad breath, tenderness 
and swelling of the gums, with a tendency to bleed, and often 
accompanied by violent stomatitis. 

Etiology. — Mercury; irritation of the lips, mouth, or 
branches of the trifacial or glossopharyngeal nerve ; irritation 
of the gastro-intestinal tract by worms; mental disorders, 
quinsy, hysteria, dropsy, and pregnancy. It also arises from 
potassium iodide, pilocarpine, and may be spontaneous or 
idiopathic. 

Symptoms. — There is a metallic taste in the mouth j gums 
are tender and bleed easily ; teeth loosen and fall out. There 
is a constant flow of saliva, and six to eight pounds are 
secreted in one day. Tongue is swollen, indented by the 
teeth, and coated. Breath is very offensive. Ulcerative 
stomatitis with slough. Saliva dribbles from the mouth, and 



176 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

patient is constantly spitting and hawking. Bowels are con- 
stipated. 

Prognosis. — Duration of two or three weeks. 

Treatment. — Prophylactic . — Be very careful in the admin- 
istration of mercury and allied drugs. Correct all possible 
causes. Give a saline cathartic, with a small amount of opium 
to prevent griping. Use local washes of boric acid, alum, tan- 
nin, carbolic acid with iodine and glycerin, compound tincture 
of capsicum and myrrh, a solution of creolin, or potassium 
chlorate and iron. Wash of peroxide of hydrogen. Rinse 
the mouth with dilute alcohol. Give concentrated diet and 
avoid all irritants. Treat symptoms. 



DISEASES OF THE PHARYNX. 



PHARYNGITIS. 

Synonyms and Varieties. — Catarrh of the pharynx ; sore 
throat ; follicular sore throat ; herpes of the pharynx ; tuber- 
cular pharyngitis, and pharyngitis sicca. • 

Etiology. — Exposure to cold, syphilis, mercury, traumatism, 
extension from nose or stomach, hot and cold liquids, chemi- 
cals and irritants of all kinds, It is symptomatic of measles, 
typhoid and scarlet fevers, rheumatism, erysipelas, and may 
be epidemic. Due to tuberculosis, debility, and bad hygiene. 

ACUTE PHARYNGITIS. 

Symptoms. — Onset with a burning feeling in one spot in 
the throat, increased on swallowing, which extends, covers the 
fauces and tonsils, causing redness and swelling. Tongue is 
heavily coated with a thick, white fur 5 great thirst and very 
bad breath, with dryness in the throat. Uvula is elongated, 
and there is a cough. Veins of the pharynx are dilated and 
prominent ; temperature may be slightly elevated. In a few 
days there is a secretion of mucus from the nose and throat, 
and cough becomes more annoying. Inflammation frequently 
spreads to the eyes, nose, ears, and lungs. Bowels are con- 
stipated, but there may be diarrhoea. 

Diagnosis. — Rarely mistaken. In fevers there is an erup- 
tion and other symptoms. 

177 



178 A SYNOPSIS OP THE PRACTICE OF MEDICINE. 

Prognosis. — Good ; lasts about one week j may extend to 
other organs or become chronic in character. 

Treatment. — If taken at once, in the first hour or two, 
when the burning is cod fined to one spot, an application 
of nitrate of silver, gr. x-f 1 i, will abort it. Cocaine acts 
locally and is only temporary. Ice or hot applications to the 
throat. One teaspoonful of liquid vaseline or cosmoline taken 
internally or applied to the pharynx will often prove efficacious. 
Dr. Waugh uses a free chlorine mixture, which will certainly 
cure if used faithfully and persistently : 

R 

Potassii chloratis 3 j. 

Acidi muriatici (U. S. P. not dil.) .... f 3jss. 

Misce, tunc adde 

Tr. ferri chloridi f 3ij. 

Aquae q. s. ad. f 3 iv. 

M. Signa. One teaspoonful, in its purity, two or three 

times a day. Do not drink water after taking. 

Gargles of potassium chlorate, carbolic acid, silver nitrate, 
or tannin are all good. Dr. Garretson recommends : 

ft 

Tr. iodi compositi gtt. xl. 

Acidi carbolici gtt. xij. 

Glycerini f I jss. 

Aquae q. s. ad. f 1 vj. 

M. Signa. Use every two or three hours as a gargle or 

spray. May use ad libitum. 

Insufflations of pyoctanin, or applications of a ten-percent, 
solution, may abort an attack. A spray or gargle of one tea- 
spoonful of peroxide of hydrogen to six teaspoonfuls of water 
will give good results. A solution of iron and potassium 



DISEASES OF THE PHARYNX. 179 

chlorate is an old but good gargle. Small doses of aconite or 
veratrum will sometimes abort it. Wine of ergot, in dram 
doses, is indicated where the tissues are relaxed. Give good 
diet, and wear flannel next the skin. Avoid exposure. 

CHRONIC PHARYNGITIS. 

Description. — Usually the result of repeated acute attacks. 
Mucous membrane is red and swollen, and the veins stand out 
and present varicosities. Mucous membrane is hypertrophied 
in patches ; cough is marked, and constant desire to hawk and 
spit. 

Treatment must be prolonged, as it is difficult to manage. 
Applications of nitrate of silver, gr. x-f 3 i, alum, tannin, or 
iodine solutions are good. Pyoctanin, aristol, or peroxide of 
hydrogen, locally, are good, new remedies. Ergot has been, 
recommended. Hydrastis, in powder, as an insufflation. Ap- 
plications of glycerol of tannin constringe the relaxed mem- 
brane. Elongated uvula should be touched with chromic acid 
or caustic, rather than cutting it off. Regulate bowels. 
Change of climate will often benefit. Applications and in- 
halations of menthol. 

FOLLICULAR PHARYNGITIS. 

Description. — Most common in clergymen {clergymen 1 s sore 
throat), weak and cachectic persons. Voice is rough, and the 
follicles stand out and may ulcerate. Tonics, iron, strychnine, 
cod-liver oil, and wine. Potassii chloras internally. Calo- 
mel and salines for the bowels. Applications of powdered 
iodoform, glycerol of tannin, or silver nitrate. Always use 
a salt-water douche or gargle-i3efore making an application 
to the throat or nose. It may be necessary to cauterize each 



180 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

follicle with galvano-eautery or caustic. Troches of potassium 
chlorate or ammonium chloride. 

HERPES OF THE PHARYNX. 

Description. — Fever, sore throat, and painful deglutition. 
Small isolated or clusters of vesicles in the throat that break 
and leave little ulcers. These vesicles may come in crops. 
They must be distinguished from diphtheria, as the latter 
spreads faster and has more constitutional symptoms. Regu- 
late the bowels with calomel or jalap, and give aconite for the 
fever. Compound tincture of benzoin, iodine, and carbolic 
acid make a good gargle. Mackenzie gives Fowler's solution 
of arsenic three times a day. Treat the ulcers as given before. 

TUBERCULAR PHARYNGITIS. 

Description. — This is an affection that occurs in tubercu- 
lar patients, and has all the characteristic symptoms of phar- 
yngitis. Food is often regurgitated through the nose or 
mouth. There are ulcers on the mucous membrane, and they 
tend to spread transversely rather than vertically. May in- 
volve the whole throat and nose. Cachexia, debility, and a 
constant fever that may run high. Dullness at the apices of 
the lungs, diarrhoea, and other signs of tuberculosis. 

Treatment is of little avail. Give best diet and cod-liver 
oil. Use enema or the stomach -tube to feed, if they cannot 
swallow. Local applications of glycerol of morphina to soothe, 
gr. i-3iii. Inhalations of medicated steam or peroxide of 
hydrogen give temporaiy relief. Koch of Berlin claims that 
tuberculosis can be cured by inoculation of a viris, but the sub- 
ject remains to be given a fair test. Cases are reported greatly 
improved. 



DISEASES OF THE PHARYNX. 181 



PHARYNGITIS SICCA. 

Description. — In this condition the throat is dry. Dry 
cough, fever, and swollen tonsils, nvnla, and pillars of the 
fauces. Suffocation may ensue from swelling. Tongue is 
broad and flabby; pulse is high. Great thirst and a nasal 
twang to the voice. Ear troubles may complicate it. Hy- 
drastis given internally and locally is the best remedy. 
Iodine, hydrochloric acid, and ammonii murias. (See other 
forms of pharyngitis.) 

PHARYNGEAL CROUP. 

Description. — This affection is rarely, if ever, seen alone, 
but usually accompanies quinsy, diphtheria, or other forms of 
croup. There is a white, membranous mass on the velum 
palati and the posterior part of the pharynx, with all the 
symptoms of a severe catarrh of the pharynx and larynx. 

Treatment. — Remove the membrane mechanically, or with 
solutions of pepsin, lactic acid, papoid, or hydrogen peroxide. 
Touch the ulcerated spots with silver nitrate and treat as in 
other forms of pharyngitis. 

QUINSY. 

Synonyms. — Tonsilitis; inflammation of the tonsils ; amyg- 
dalitis j cynanche ; phlegmonous pharyngitis. 

Definition. — An acute inflammation of the parenchyma of 
one or both tonsils, which tends to formation of pus, accom- 
panied by chill, rise of temperature, pain on talking or deglu- 
tition, and a nasal twang to the voice. 

Etiology. — -Acute quinsy comes from exposure to cold, pre- 



182 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

disposition, acute rheumatism, sewer-gas, bad hygiene, epi- 
demics, and diathesis. Chronic quinsy comes from repeated 
acute attacks, scrofula, teething, and is most common in 
the spring and fall, in males between fifteen and twenty-five 
years of age. One attack predisposes to another on the 
slightest provocation. 

Symptoms. — Onset. — A chill or rigor, with a rise of tem- 
perature as high as 104° F. at times. Pulse is rapid, pains 
in the bones, anorexia, thirst, delirium, headache, dryness and 
aching of the fauces, and a swelling at the angle of the jaw. 
Great pain on every effort at swallowing. Urine is scanty, 
dark, and high-colored ; tongue is heavily furred, and breath 
bad. Glands of the neck and the salivary glands are swollen. 
Salivation may be present. Respiration is unaffected until 
the tonsils become swollen, and there may then be very alarm- 
ing dyspnoea. Inflammation may extend to the middle ear or 
other organs. One tonsil is affected at a time, then the other. 
Tonsil is red, swollen, tender, and covered with thick mucus. 
Symptoms gradually increase from three to five days, fol- 
lowed by resolution or suppuration. Throbbing pain, with 
increased fever and depression, and the abscess may then 
point or break into the throat, side of the neck, or, rarely, 
may burrow down along the neck to the pleural cavity and 
give rise to a pleurisy. Recovery takes place in about two 
weeks. If both sides are affected at once, there may be great 
dyspnoea, which will result in suffocation unless promptly re- 
lieved. When the abscess breaks, it may cause fatal stran- 
gulation by the pus entering the bronchial tubes ; but this is 
rare. Slight hemorrhages from the tonsil are common. If 
suppuration does not take place (blind quinsy), it will run its 
course in about four days. 

Chronic Tonsilitis, or Hypertrophy. — Tonsils are hard and 
large, and can be felt at the angles of the jaw externally. 



DISEASES OF THE PHARYNX. 183 

They project into the throat ; may meet and ulcerate on the 
opposing surfaces. They are smooth and shiny, and the fol- 
licles show. Pale red in color, with yellow or white curdy 
masses protruding from the follicles. Liable to frequent at- 
tacks of inflammation. Patient is pale, weak, and anaemic. 
Nasal voice ; sleeps with the mouth open, and makes a snoring 
noise. Bowels are constipated, and a hoarse, paroxysmal 
cough is present. Chest is more or less sunken from labored 
respiration. Uvula is elongated. 

Pathology. — Acute. — Inflammation of one or both tonsils 
and an exudation of tough, tenacious mucus adherent to their 
surface. Crypts of the tonsils are enlarged, and small, white 
or yellow masses are seen protruding from them. Lymphatic 
follicles swell and form small abscesses which merge into one, 
that points in the throat, behind the ear, or burrows along the 
neck to the thorax. 

Chronic. — A permanent hypertrophy from chronic inflam- 
mation of the submucous tissue. Glands are very large, and 
often meet in the median line and ulcerate on their opposing 
surfaces. 

Diagnosis. — Diphtheria has an ash-colored membrane which 
spreads rapidly ; is unlike the curdy mass of quinsy, and has 
more marked swelling of the cervical glands. 

Prognosis. — Good; runs its course in one or two weeks. 
It will either suppurate or go on to resolution. Death may 
ensue from breaking of abscess or swelling. Chronic form is 
not so hopeful as to cure, but can be greatly benefited. 

Treatment. — Prophylactic treatment consists in avoiding 
exposure to cold or irritating causes. The use of such astrin- 
gents as tannic acid and its solutions, locally, keeps the parts 
constringed. 

Abortive Treatment. — Mackenzie recommends resina guaiaci, 
gr. ij, in the form of a lozenge, every two hours. Applications 



184 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

of solid nitrate of silver at the onset. Tincture of aconite, 
gtt. ss, every ten minutes, until fever is broken. When due 
to cold, a large dose of Dover's powder, gr. x, and hot drinks, 
followed by a free mercurial purge. Salicylate of soda or 
salicylic acid is almost a specific when there is a suspicion of 
rheumatism. A free saline purge, followed by wine of anti- 
mony, or tartar emetic, gr. J to i, ever}' hour, has been recom- 
mended. Large doses of belladonna are said to abort. 
One third of a grain of hydrargyrum cum creta, every hour, 
will reduce swelling and obviate danger. Sulphide of calcium, 
gr. to to j, every three hours, will prevent suppuration, if a 
good preparation is used. Emetics are used by some, but are 
of doubtful utility. Raymond applies pure guaiacol and fol- 
lows by keeping the throat moist. 

General Treatment. — Give hot drinks and gargles, and apply 
poultices to the angle of the jaw. Hot inunctions of ich- 
thyol ointment, ten percent. On the other hand, pellets of 
ice may be used to give relief. Give a free purge of calomel 
and jalap to deplete. Inhalations of pure or medicated 
steam or peroxide of hydrogen. Scarify the tonsil deeply. 
Incise from within out to avoid wounding the internal carotid. 
Syrup of the iodide of iron is recommended. Give iron and 
quinine through the attack. Potassium chlorate, gr. v, every 
four hours. Astringent gargles in the earl}' stages do good, 
but in the later stages they do harm. Applications of sub- 
acetate of lead, once daily, often relieve. When pus is present, 
incise freely and give hot gargles. Diet should consist of 
milk, broth, egg-nog, and wine. In the non- suppurative form, 
give, every six hours : 

Magnesii sulphatis 3 ss. 

Quininae sulphatis . ...... , . : . . . . gr. ij. 

Acidi sulphurici diluti, , ,,,..... . gtt. v. M. 



BSSEASES OF THE PHARYNX. 185 

Chronic Tonsilitis. — Improve nutrition and regulate diges- 
tion. Cod-liver oil, iron and wine tonics. Wear flannel next 
the skin. Equal parts of calcium sulphide and iodoform, 
gr. -J, seem to reduce the gland, as does syr. ferri iodidi. 
Local excision or application of London paste to remove the 
glands. Never excise unless absolutely necessary. Gangrene 
is prevented by free incisions. Chromic-acid gargles for their 
antiseptic and astringent virtues. Local applications of iron, 
iodine, and glycerin, or nitrate of silver, to palliate. Pro- 
fessor Penrose says that if a man's tonsils are excised he 
will be impotent and have no children. This is not wholly 
confirmed by statistics. Application of a mild galvanic cur- 
rent, positive pole to the tonsil and the negative to the side 
of the neck, has reduced it. Nature will sometimes relieve 
the size after the age of puberty has passed. 

SYPHILIS OF THE PHARYNX. 

Description. — Syphilis of the pharynx may appear in the 
form of gummatous tumors or excrescences. Small papules 
may appear on the tonsils. Ulcers, with a raw-meat-like 
appearance and irregular edges, appear on the mucous mem- 
brane. Mucous membrane of the soft palate and tonsils may 
ulcerate away. Deafness may occur from extension of inflam- 
mation or closure of the Eustachian tubes. The posterior part 
of the uvula is a common seat for ulcers and excrescences. 
Specific history is usually obtainable and aids in diagnosis. 

Treatment. — Specific medication with mercury and the 
iodides. Treat gummata and ulcers with acid nitrate of 
mercury, galvano-cautery, and dress with some antiseptic. 



186 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



HERPES OF THE TONSILS. 

Definition and Symptoms. — A disease of the tonsils, char- 
acterized by the formation of little blisters or vesicles which 
contain clear serum. It is usually accompanied by chills, 
rigors, and intense pain on one side of the throat. Exami- 
nation shows a crop of little vesicles on the tonsil, and these 
may extend to the pharynx and larynx. Pulse and tempera- 
ture are high. 

Diagnosis. — This condition and diphtheria are very much 
alike. Pain on swallowing is greater than in diphtheria, 
and there is little or no headache. No spreading membrane 
in herpes, and only lasts one or two days. 

Treatment. — Free purgation. Fever mixture if needed. 
Treat as indicated in catarrh, and combat symptoms as they 
arise. 

RETROPHARYNGEAL ABSCESS. 

Definition. — A collection of pus in the loose, cellular, con- 
nective tissue between the posterior wall of the pharynx and 
bodies of the cervical vertebra, most common in young chil- 
dren. 

Etiology. — Most frequent cause is caries of the vertebra. 
May occur in course of measles, scarlet fever, diphtheria, scrof- 
ula, erysipelas, or typhoid fever. May be idiopathic. Most 
common in infants under one year of age. Direct injury, 
mechanical or chemical, tonsilitis, or exposure to cold. 

Symptoms. — Great difficulty in breathing and swallowing. 
Unable to take any solid food on account of swelling at the 
back of pharynx. They breathe through the mouth, and have 
a nasal but not rough voice. Dyspnoea is great, and increased 
by lying down. Chest and epigastrium sink from efforts at 



DISEASES OF THE PHARYNX. 187 

respiration. Suffocation may ensue from swelling* or break- 
ing of the abscess. There is a hard, dry, and ringing cough 
like that heard in pertussis. Back of the pharynx bulges for- 
ward, is soft and fluctuating to the touch, or may feel hard. 
Pus may penetrate the walls of pharynx, neck, or burrow 
along the neck to the mediastinum. Patient may be unable 
to open his jaws or move the head on account of the intense 
pain and muscular rigidity. In the acute form there is high 
fever. 

Diagnosis. — It closely resembles croup. Croup has no re- 
tropharyngeal swelling, and has a husky voice. Abscess has 
swelling and a husky voice. It is easily distinguished from 
swelling of the epiglottis. 

Prognosis. — Favorable, if taken early, and lasts from one 
to three weeks. Occurring in the course of a septic fever, 
abscess is a bad sign and usually means death. Suffocation 
may ensue. 

Treatment. — Open abscess at once in the median line, at 
its lowest point, with a guarded bistoury. A trochar and 
cannula may be used if there is fear of pus causing strangu- 
lation. Use gentle pressure on the abscess after it has been 
opened to keep it evacuated ; and if cleansed with hydrogen 
peroxide or pyoctanin it will heal much more readily and 
will secrete little or no pus after the application. Use anti- 
septic washes and applications. Give the very best diet and 
stimulants. Cod-liver oil and quinine as well as the best of 
hygiene. Sulphide of calcium may be of benefit in one-eighth- 
grain doses every three hours. 

ANGINA LUDOVICI. 

Synonym. — Abscess of the floor of the mouth. 

Etiology. — Complicates typhus fever, erysipelas, or other 



188 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

» 

septic fevers. Arises from injuries, scrofula, debility, and 
extending inflammation, or may be idiopathic. 

Symptoms. — A painful swelling near the submaxillary 
gland, which is hard, red, and shiny. Great pain is present 
when an attempt is made to open the mouth, swallow, or talk. 
Slight fever. Abscess may point and open into the mouth or 
on the neck. Death may ensue from swelling, septic poison- 
ing, or gangrene. 

Treatment. — Apply cold or hot poultices. Applications of 
equal parts of belladonna and mercury ointment, well rubbed 
in, when hot, will remove induration. Ichthyol ointment or 
blisters will often give good results. Evacuate pus as soon 
as formed, taking care to open abscess in the line of wrinkles 
of the face, so that a scar will not show. Sulphide of calcium 
reduces tendency to pus-formation. 



DISEASES OF THE (ESOPHAGUS. 



OESOPHAGITIS. 

Etiology. — Chemical, mechanical, or thermal agents. Hot 
water; corrosive poisons, snch as nitric acid, snlphnric and 
carbolic acids, ammonia, and canstic lye. Foreign bodies, 
pressure of tumors or anenrism, heart-disease, extension of 
inflammation, or cancer. 

Definition. — An inflammation of the mucous and submu- 
cous tissues of the oesophagus, characterized by pain, difficulty 
on swallowing (dysphagia), hiccup, fever, and a burning pain 
between the shoulders and behind the sternum. 

Varieties. — (1) Follicular; (2) croupous, which is rare; 
(3) pustular, in smallpox or tartar-emetic poisoning; (4) ul- 
cers ; (5) submucous inflammation ; (6) burns. 

Symptoms. — Since there is little sensibility in the oesopha- 
gus, there is not much pain. A burning, dull pain felt be- 
tween the shoulders and on the chest behind the manubrium 
sterni. Food cannot be swallowed, but is regurgitated with a 
bloody mucus. Hiccup is a constant symptom. Fever varies 
with inflammation. Dry, burning sensation in the throat. 
Ulcers may form, and are recognized by localized tenderness 
when the probang is passed. Perforation may take place. 

Pathology. — That of any inflammation. 

Prognosis. — May terminate in slow, complete recovery or 
in stricture from contraction of cicatricial tissue. 

189 



190 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Treatment. — Remove any foreign bodies with proper sur- 
gical means. In case of corrosive poisons, give morphina, gr. 
■§■ to Ttj with bismuth subnitrate, gr. v-xx, every three or f onr 
hours, to control pain and burning. When catarrh is acute, 
use ice and frequent sips of cold water. Give the blandest 
liquid diet, and nourish by enema or stomach- tube. If the 
ulcers can be reached with a tube or brush, touch them with 
silver nitrate, gr. xx-?j. When inflammation subsides, pass 
a bougie regularly for six months or a year to prevent stric- 
ture. Mild galvanization with a bougie electrode is of great 
service. 

STRICTURE OF THE (ESOPHAGUS. 

Definition. — A narrowing or obstruction of the normal 
caliber of the oesophagus, that is either spasmodic, organic, or 
malignant in character. 

Etiology. — Cicatrices, pressure of enlarged glands, aneu- 
rism, abscesses, syphilis, lodgment of foreign bodies, chronic 
inflammation, and cancer; hysteria, hypochondriasis, ner- 
vous and psychic causes. Sometimes congenital. 

Symptoms. — Spasmodic or functional stricture is due to a 
spasmodic contraction of the oesophageal muscle under a state 
of hysteria or hypochondriasis. Not constant, and in the in- 
tervals patient can take food. During spasm, food sticks and 
causes choking pains in the oesophagus, and finally regurgita- 
tion of food, with other hysterical manifestations. A bougie 
can be passed after a few days' persistent use. 

Organic stricture is most common in the lower third. There 
is great difficulty in swallowing liquids, and ultimately no 
food can be taken. A bougie will pass with difficulty if in- 
complete, or will not pass at all if complete. Patient wastes 
and loses flesh. 



DISEASES OF THE (ESOPHAGUS. 191 

Malignant stricture of the oesophagus is primary. Epitheli- 
oma is the most common form, in the middle of the tube or 
at the cardiac orifice. Foul eructations of food and bloody 
mucus, with marked cachexia and wasting. 

Diagnosis. — Confirmed by passage of the bougie. 

Prognosis. — Usually grave, and a cure is rare. 

Treatment. — In the spasmodic form, gain the confidence of 
the patient and make a marked mental impression. Correct 
secondary troubles and pass the bougie frequently. Use an 
electric battery. Bromides and sedatives may do some good, 
but change of scene and mental impression will accomplish 
more. 

Organic stricture, due to inflammation, demands frequent 
passage of the bougie. Better than this, and combined with 
it, is electrolysis. The positive pole is placed to the left of the 
spine, at the ninth rib, while the negative electrode is gently 
introduced to the seat of the stricture, and a mild galvanic 
current used for three minutes at a time until it passes it. 
Alimentation is effected through the stomach-tube or rectum 
with peptonized foods, taking care not to give more than 
four ounces at one time, after the bowels have been emptied. 
A larger quantity will irritate and prevent absorption. 

Malignant stricture is hopeless. Surgical operations, such 
as gastrotomy, gastrostomy, oesophagotomy, and others, are 
resorted to. A bougie should not be used in case of cancer 
or aneurysm, as rupture is liable to follow. In aneurysm, treat 
with potassium iodide, aconite, and surgical means. 

DILATATION OF THE (ESOPHAGUS. 

Description. — This is a comparatively rare condition, and 
consists of a pouch or dilatation in a portion of the oesopha- 
gus, with or without stricture. It may be due to pressure, 



192 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

adhesions, or paralysis. Most commonly associated with 
stricture. It is characterized by a regurgitation of food and 
alkaline mucus. The trachea or vessels of the neck may be 
compressed. Difficulty in swallowing. There is a swelling 
in the neck, most marked after eating and diminished after 
vomiting or pressure. Loss of flesh and strength. 

Treatment. — Of little avail. Astringents have been recom- 
mended. Galvanism or faradism by means of an electrode 
bougie furnishes most hope of restoring muscular tone to the 
affected part. Nourish by stomach-tube or rectal alimentation. 



DISEASES OF THE STOMACH. 



ACUTE GASTRIC CATARRH. 

Synonyms. — Gastritis; acute indigestion; bilious fever; 
gastric fever ; catarrh of the stomach. 

Definition. — An inflammation of the mucons membrane of 
the stomach, characterized by diminished, then increased, 
secretion, with impairment of digestive function. 

Etiology. — Overtaxed physiological action, debility, fevers, 
age, quality and quantity of food, improper mastication and 
ensalivation, over-feeding, hot drinks, and irritants. Eating 
ice-cream after meals, drinking ice-water, or catching cold. 
Opium, arsenic, tartar emetic, worms, impoverished or dimin- 
ished gastric juice, dentition, improper hygiene, predisposition, 
or extension from other parts. Sometimes epidemic. 

Symptoms. — Patient is dull and fretful; waves of heat 
and cold ; cold extremities. General malaise, thirst, headache, 
and tenderness and fullness in the epigastric region. Belch 
fetid gas and sour liquid. Epigastrium is prominent ; tongue 
is heavily coated with a yellowish- white fur, and red at the 
edges. Breath very bad ; persistent nausea and vomiting of 
undigested food, mucus, and, finally, bile. Bowels may be 
loose or constipated. Pulse weak and fluttering ; intolerance 
of light, and a tendency to stomachic vertigo. Ingestion of 
food increases it. There is very slight fever, but in children 
it may run very high. Urine is loaded with lithates, pigment, 
or uric acid. There may be cerebral trouble in the aged. 

193 



194 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

Another form is that in which there is a severe attack of 
headache, with violent retching and vomiting of bilious mat- 
ter. It passes away in a few days, and is known as bilious or 
sick headache. 

Pathology. — Mucons membrane is dark red ; may be soft- 
ened in spots, and is covered with thick alkaline mucus or 
muco-pus. Gastric juice is diminished or entirely suppressed, 
and the subglandular and submucous tissues are infiltrated. 
Fermenting food is often found in the stomach, due to the 
bacillus lacticus. 

Diagnosis. — In simple dyspepsia, acids and spices give re- 
lief ) in gastric catarrh or structural lesions they cause pain. 
Typhoid and remittent fever show their characteristic points, 
but maybe confounded at first. Peritonitis is more rapid and 
severe ; collapse is early, and pain is more diffuse. 

Prognosis. — When uncomplicated, is good. One or two 
weeks 7 duration, or may become chronic. 

Treatment. — Diet should be regulated first. When there 
is vomiting of sour and undigested food, mixed with mucus, 
give an emetic of pulv. ipecacuanhae, gr. x-xv, in warm water, 
to which has been added a little sodium bicarbonate. Wine 
of antimony or zinc sulphate may be used as emetics, but 
must not be repeated. Follow this with 

Tr. nucis vomicae til j-iij. 

Sodii bicarbonatis gr. iv-vj. 

Spts. chloroformi . n L j-iij. 

Aquae q. s. ad. f 3 j. 

M. Signa. Three times a day, to restore the mucous mem- 
brane to health. (E. Smith.) 

If the bowels are involved, give castor-oil or syr. rhei aro- 
maticus. Alkalies, glycozone, or hydrogen peroxide will coun- 



DISEASES OF THE STOMACH. 195 

teract acidity. Severe cases may require silver nitrate or oxide. 
If emetics are not indicated, begin by giving 

Sodii carbonatis 3ij. 

Vini ipecacuanhas f 3ij. 

Ext. rhei fluidi f 3ij. 

Syr. rhei q. s. ad. f 5 iij. 

M. Signa. A dessertspoonful in a tea-cup of hot water one 
hour before meals. (Waugh.) 

This will clear the stomach of mucus, and acts best in sub- 
acute and chronic forms. It is sometimes necessary to aid 
digestion by one or all the digestants. In vomiting, with vio- 
lent headache (bilious attack), nothing will act better than 

ft 

Cupri arsenitis gr. 1/100. 

Ext. nucis vomicae fld gtt. viij. 

Aquae f § iij. 

M. Signa. One teaspoonful every ten or twenty minutes 

until relieved. 

Vomiting will cease after a few doses, and headache will dis- 
appear. Place mustard over the stomach at the same time, and 
rest in bed. Follow with a free calomel purge. Bismuth, 
calomel, sulphocarbolate of zinc, liq. arsenii, and a host of 
other remedies are recommended to relieve vomiting and diar- 
rhoea. Glycozone, 3 i-ij, is healing. Small doses of opium 
or morphina will relieve pain. When gastritis is complicated 
by fever, give fluids, such as rice-soup, hydrochloric acid and 
the carbonated waters — seltzer, vichy, or soda waters. Avoid 
all spices, alcohol, and condiments. Fermentation will be 
checked by sulphocarbolate of zinc, gr. iij, every three hours, 
or hydrogen peroxide, 3 ss-j, in water, every three to four 
hours. Rheum, with an alkali j salol, gr. v, every two hours ; 
carbolic acid, aristol, or iodoform also check fermentation. 



196 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

During convalescence, give tonics of iron or glycerol of 
the phosphates to avoid syrup in ordinary preparations. 

Diet. — At first give unsweetened barley- water, rice-water, and 
fresh curds and whey. Good broths, to which dry toast may be 
added sparingly. Later, milk with lime-water. Avoid sugars, 
pastries, potatoes, or starches. Later, a little fresh chicken 
or mutton may be taken sparingly. Dilute hydrochloric 
acid, gtt. xv-xx, in a glass of water, to be sipped at intervals 
during the meal, will stop lactic-acid fermentation. In pyrosis , 
subnitrate of bismuth, ad libitum, is the best remedy. 

CHRONIC GASTRIC CATARRH. 

Synonyms. — Chronic gastritis ; drunkard's catarrh. 

Definition. — A chronic inflammation of the mucous and 
submucous membranes of the stomach, characterized by dis- 
ordered digestion, tenderness on pressure, and atrophy of the 
glands of the stomach. It is not a chronic dyspepsia, but may 
be one of the results of this condition. 

Etiology. — Excessive use of alcohol; improper foods and 
condiments ; frequent acute attacks ; and cancer. May be sec- 
ondary to diseases of the heart, liver, lungs, pleura, kidneys, 
or portal system, causing a congestion of the venous system 
of the stomach. 

Symptoms. — Pain and distress immediately after eating. 
Pyrosis, and belching fetid gas ; appetite may be ravenous, 
especially in women. Early morning vomiting of glairy mucus 
is characteristic in drunkards. Constipation is the rule. An- 
orexia; thirst; tongue coated in center and red at tip and 
edges ; lips dry and cracked ; bad breath ; vertigo ; headache ; 
weak heart ; and insomnia. Some local tenderness in the epi- 
gastrium. 

Pain is burning in character at the pit of the stomach, 



DISEASES OF THE STOMACH. 197 

and often reflected between the shoulders. Epigastrium is 
distended. Nervousness, depression, and emaciation ensue. 
Pharyngeal and bowel troubles complicate it. There is a 
sympathetic or stomach cough. 

Pathology. — The mucous walls of the stomach are coarse, 
thickened, and gray or brown. Pigmentation is most marked 
at the pylorus. Walls of the stomach covered with tough 
mucus. Obliteration and atrophy of the peptic glands in 
places j ridges radiate through it, giving rise to a mammillated 
appearance. Sometimes the stomach resembles a fibrous bag. 
Mucus prevents food from coming in contact with the gastric 
walls ; hence the necessity for its removal before normal diges- 
tion begins. 

Diagnosis. — Atonic dijspepsia has no structural lesion ; no 
vomiting of glairy mucus ; no constant local tenderness ; no 
fever ; and little pain after eating. From cancer and ulcer (see 
Gastric Cancer). 

Prognosis. — Not fatal. May terminate in ulceration or 
stenosis of the pylorus. We cannot restore destroyed glands, 
but can retain those left. 

Treatment. — Avoid alcoholics, spices, and condiments at 
the earliest time possible. Diet of toasted bread, milk, and 
foods that have been predigested with pepsin, diastase, or 
paucreatin. Rest the stomach as well as the body. To get 
rid of mucus, the prescription on page 195 should be used 
until all is taken. Follow this with : 

Argenti oxidi gr. 1/4. 

Zinci oxidi gr*. ij. 

Misce. Fiat pil. No. 1. Signa. Three times, daily, fifteen 
minutes before meals, for two weeks. 

Papoicl, gr. i-ij, is one of the best remedies in gastric ca- 
tarrh, as it will digest mucus if given previous to a meal and 



198 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

followed later by a glass of hot water. Pure pepsin must be 
used with caution, as it will often digest the walls of the stom- 
ach. Lactopepsin is best and safest. Liq. potassii arsenitis, 
gtt. i-ij, is highly recommended. Morphina or the opiates, 
with belladonna, for pain. Washing out the stomach (lavage) 
with antiseptic washes is recommended to remove mucus, 
but is unpleasant, and in many cases unnecessary, as other 
methods will answer. Glycozone, 3 i-ij ter die, is highly recom- 
mended for its healing power. Each case has its own peculi- 
arities and requires symptomatic treatment ; no set rule can 
be given. 

When catarrh is secondary to other troubles, treat the cause 
and remove it if possible. 

GASTRITIS PHLEGMONOSA. 

Synonyms. — Phlegmonous gastritis ; acute suppurative 
gastritis. 

Definition. — An acute, diffuse, suppurative inflammation 
of the mucous and submucous tissues of the stomach, rarely 
seen and rapidly fatal. It occurs primarily or secondarily. 

Symptoms. — There is very high pywmic fever ; quick pulse ; 
bad breath ; coated tongue ; very severe, constant, and per- 
sistent pain in epigastrium, and persistent vomiting of mucus 
or pus. May be sudden collapse from perforation. Abscess 
may be felt as a tumor, and may break into the stomach, per- 
itoneum, or even perforate the diaphragm or skin. 

Pathology. — Mucous membrane is red and thickened. Ah- 
scesses are found in the submucous tissue, and an infiltration of 
pus into surrounding structures. Muscular coat is involved, 
and stomach may adhere to surrounding organs. Sinuses 
and perforation may be found. Ulcers heal by cicatrix. The 
Germans compare it to phlegmonous- or pseudo-erysipelas. 



DISEASES OF THE STOMACH, 199 

Diagnosis. — Persistent pain, high pyaemic fever, and vomit- 
ing of pus at times. Rarely possible to diagnose it during 
life. 

Prognosis. — Usually fatal, but may recover. 

Treatment. — Opium, to relieve pain. Cocaine and glyco- 
zone are recommended. Check vomiting with appropriate 
remedies. No food or water should pass the stomach, but 
patient should be fed per rectum. Quinine, and in some cases 
alcohol, per rectum. Give the stomach absolute rest, and avoid 
all depressants. If abscess is diagnosed, operate at once. 

TOXIC GASTRITIS. 

Synonyms. — Acute gastritis ; gastritis from poisons. 

Definition. — An acute inflammation of the mucous, sub- 
mucous, and muscular walls of the stomach, due to the action 
of some corrosive poison, and characterized by intense pain 
and vomiting of bloody matter and often portions of the 
eroded mass. 

Symptoms. — Great anxiety, fear, pallor, and cold extremi- 
ties, with cold sweat and irregular action of the heart. Breath- 
ing is rapid and shallow. Severe burning along the oesopha- 
gus and in the stomach. Often vomiting of bloody mucus or 
masses of the eroded mucous membrane. Thirst and intense 
burning in the throat. Patient may go into collapse and die, 
or gradually recover with permanent impairment of part of 
the stomach, oesophagus, or both. Fatal hemorrhage may 
ensue from erosion of a vessel. 

Pathology. — Mucous membrane of the mouth, throat, and 
stomach is red and injected. Pulpy spots and erosion of the 
mucous membrane. May be perforation of the walls of the 
stomach. Glands are destroyed in places, and the peculiar 
characteristics of each poison are noticed. Corrosive acids pro- 



200 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

duce slough with hard eschar. Alkalies cause a pulpy appear- 
ance. Arsenic leaves white, corroded spots that are covered 
with white powder and slough, and have red folds radiating 
from them. Ethereal oils give catarrhal symptoms, sudden 
pain in the abdomen, and vomiting. Sulphuric acid chars 
black. Nitric acid stains yellow. Carbolic acid stains white. 

Prognosis. — Grave, and depends on the character, amount 
of poison taken, and the antidotes given. Stricture of the 
oesophagus is a common sequel. 

Treatment. — Take in the whole situation at a glance and 
note surroundings ; take possession of all empty bottles, and 
preserve all vomited matter for future examination. Antidotes 
in corrosive poisons are usually useless, as the damage is done 
by the time you arrive or administer them. Alkalies will 
neutralize acids. Arsenic, which is slowly absorbed, requires 
administration of sesquioxide of iron, followed by a free 
emetic of ipecac. May use stomach-pump. In corrosive acids 
and alkalies, never give water, but administer free draughts of 
oil. For the pain, give morphinse sulphas, gr. rg- to §-, and 
bismuthi subnitras, gr. v-xx, every three or four hours, as it 
relieves almost immediately. Ice, internally and externally, 
relieves pain. Cocaine or glycozone. Give the stomach abso- 
lute rest and feed per rectum. Combat subsequent inflam- 
mation as already indicated. Stimulate freely, if indicated. 
Treat each case according to the poison taken. Symptomatic 
treatment. 

GASTRIC ULCER. 

Definition. — A solution of the continuity of the walls of 
the stomach, that may involve one or more coats, characterized 
by peculiar, localized pain, vomiting of blood, and perverted 
function of digestion. 



DISEASES OF THE STOMACH. 201 

Etiology. — Ulcer is most common in women at the age of 
twenty-one years, and rare in children. Occlusion of a twig 
of an artery from emboli ; due to disease of the heart, lung, 
kidney, or liver. Obstruction of any kind to the circulation. 
Gastric catarrh, anaemia, chlorosis, lack of nutrition, chronic 
congestion, vicarious menstruation, erosions from poisons, 
portal obstructions, concentrated forms of pepsin, and gastric 
juice itself. Amyloid degeneration of the vessels. 

Symptoms. — Indigestion and its symptoms. Usually as- 
sociated with anaemia and gastric catarrh. The two character- 
istic symptoms are pain and vomiting. 

Pain is rarely absent; is persistent in the epigastrium in 
one spot ; increased by pressure and taking food ; is severe, 
gnawing, paroxysmal, and radiates between the shoulders, 
down the spine, or behind the ensiform cartilage. It is re- 
flected to the right or left hypochondrium or the lower dorsal 
vertebra, and worst fifteen minutes after eating. Paroxysms 
are severe and last several hours or days. Pain may come 
on after eating or between meals. The recumbent posture 
affords slight relief. Patient sighs, groans, and is relieved 
after vomiting. Increased pain immediately after taking 
food indicates ulcer at the cardiac orifice ; when pain comes 
on after an hour or more, it is at the pylorus. 

Vomiting is as constant as pain, and occurs at once after 
eating if the ulcer is at the cardiac end, but if at the pyloric, 
will not occur for a few hours. The vomited matter contains 
pure red or clotted blood ; or, if it remains in the stomach 
some time, is black or like coffee-grounds. Blood may pass 
per rectum as black, tarry masses. Tongue is red and smooth, 
and there is great thirst. Gastralgia is much increased oy tak- 
ing food. Debility and no fever. Appetite is often unim- 
paired. Constipation. Perforation causes violent peritonitis 
and death. Gastric ulcer may lie latent and cause no symp- 



202 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

toms that will lead to its detection until sudden hemorrhage 
or perforation occurs. 

Pathology. — Single or multiple ulcers are found at the 
pylorus or back of the stomach. They are circular, oval, and 
funnel-shaped, with thin edges at first, but afterward thick- 
ened. They measure from one quarter to one inch in diame- 
ter. One or more coats of the stomach are eroded, and may 
perforate the diaphragm, peritoneum, or the skin, giving rise 
to a gastro-cutaneous fistula which may remain open for years. 
May be adhesions to other organs. Eroded vessels and gen- 
eral inflammation around the ulcer. Cicatrices of healed 
ulcers are sometimes found. Pain is due to the action of 
acid gastric juice or localized peritonitis. Hemorrhage comes 
from eroded vessels. Old ulcers may become cancerous in the 
aged. The exact causation of an ulcer is not fully explained. 

Diagnosis. — Made from age, vomiting of blood, peculiar, 
localized pain, and absence of tumor. (See Cancer, p. 205.) 

Prognosis. — Must be guarded, but most cases recover. 
May be obstruction of the pylorus, fatal hemorrhage, or per- 
foration. Death ensues from exhaustion, hemorrhage, or peri- 
tonitis. Lasts for a few months or continues for years. 

Treatment. — Diet. — When food can be retained, give the 
most agreeable diet in small quantities. No sugars, spices, 
condiments, hot drinks, or alcoholics, as they cause pain. 
White of egg, beaten up in pure, cold water, is good. Pepton- 
ized milk, curds and whey, rice, corn-starch, tapioca, and sago 
are all excellent articles of diet. Raw beef, reduced to a pulp. 
If stomach is irritable, give absolute rest and feed per rectum. 
Great relief is obtained by the administration of morphina, 
gr. Ve to ■§-, or atrophia? sulphas, gr. T ^o> or powdered opium 
and soap in pill form. Cocaine and iodoform are of little 
benefit. Oxide of silver, gr. }, with oxide of zinc, gr. ij, in pill 
form, before meals and at bedtime, gives great relief. Nitrate 



DISEASES OF THE STOMACH. 203 

of silver, gr. \- ; bismuth subnitrate, gr. xx ; glycozone, f 3 i-ij • 
or liq. potassii arsenitis, gtt. i-ij, do good. Do not give silver 
too loug on account of argyria. Blisters and local irritation 
over the epigastrium often relieve. The Germans use the 
alkaline carbonates or sodium sulphate. Sodium is not suit- 
able in anaemic cases, but will answer in plethora. Carlsbad 
water will check acid secretion. Vomiting must be controlled 
and cathartics cautiously used. Rectal injections of cold 
water. Salts or compound licorice-powder should be given 
the preference to open the bowels. 

In hcematemesis give ice internally and apply it over the 
epigastrium. Acetate of lead, iron, alum, turpentine, or tan- 
nic acid internally, or ergotine, gr. i-ij, bypoclermically. Zinc 
sulphocarbolate, gr. v, every three hours, stopped severe hem- 
orrhage in a number of cases. When due to vicarious men- 
struation, give emmenagogues before the period. Marriage is 
said to cure some cases. In perforation, put patient on opiates 
and keep quiet in bed. When there is a syphilitic history, 
potassium iodide will relieve when all other remedies fail. 

Lavage is highly recommended by later writers and clini- 
cians. Use a solution of sodium sulphate, chloride, biborate 
or bicarbonate, 3 i-ij in Oij of warm water. Antiseptic solu- 
tions are resorcin, one percent. ; boric acid, one percent. ; creo- 
sote, carbolic acid, or creolin, one percent. Surgical interfer- 
ence may be necessary in perforation. 



GASTRIC CANCER. 

Synonyms. — Carcinoma, or cancer of the stomach. 

Definition. — A malignant growth in the stomach occurring 
after the fortieth year, characterized by cachexia, localized 
pain, vomiting, and tumor, and terminating fatally. 



204 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Etiology. — Most common, after the fortieth year, in women. 
Hereditary. Gastric nicer and all irritants in those who have 
a tendency to it. Secondary to other cancers, bnt mostly pri- 
mary. 

Symptoms. — Sense of pressure and fullness in the epigas- 
trium 5 oedema of the ankles 5 dyspepsia 5 cachexia j anaemia 
and marasmus. Vomiting occurs immediately after eating if 
at the cardiac end ; or, if at the pyloric, vomiting takes place 
in a few hours. Regurgitation of food indicates stricture, di- 
latation, or ulceration of the cardiac orifice. Vomited matter 
consists of mucus, sour liquid, and the characteristic coffee- 
ground vomit. Hemorrhage is frequent and in small amounts. 
Profuse hemorrhage indicates ulceration. There is an ab- 
sence or diminution of hydrochloric acid in the secretions of the 
stomach.* 

Pain is constant, dull or lancinating, in one spot, and is 
independent of eating. Temperature is elevated at times. 
Tumor in epigastric region is the most certain sign, is the 
size of a pigeon's egg or larger, and is not very sensitive to the 
touch. A medullary tumor is nodulated. Percussion is not 
clear. Dilatation or involvement of other organs is common. 
Skin is a dirty- white or fawn color. Colloid cancer gives rise 
to constipation and ascites. Tongue is red and dry, and loss 
of flesh and strength is rapid. Death occurs from peritonitis, 
hemorrhage, or exhaustion, in six months to two years. 

* Giinzburg\$ Test for Free Hydrochloric Acid. — Mix phloroglucin, two 
parts ; vanillin, one part; absolute alcohol, thirty parts. Filter gastric 
contents, and to one drop, on a white plate, add one drop of this solu- 
tion ; evaporate to dryness over a flame, and a rose-red color appears at 
the edge if free acid is present. Free acid is also demonstrated by tro- 
pasolin or Congo paper. 

Lactic acid is shown by taking one or two drops of tr. ferri chloridi and 
ten or twenty drops of a five-percent, solution of carbolic acid, and dilute 
to an amethyst-blue with water. Add gastric fluid, and, if lactic acid is 
present, it is changed to a clear lemon-yellow. 



DISEASES OP THE STOMACH. 



205 



Pathology. — The stomach, is the most frequent seat of can- 
cer 5 is primary or secondary ; most common at the pylorus. 
Scirrhous is most usual, medullary next, and colloid least 
common. Colloid cancer causes a diffuse degeneration, and 
may extend to the intestines and cause atrophy of the car- 
diac end of the stomach. Hard, infiltrated nodules or ulcer- 
ated masses are found. Pylorus may be obstructed and 
stomach dilated. Glands of the stomach are infiltrated, and 
the mucous membrane is hypertrophied. Begins in submucous 
tissue and spreads. Vomiting is due to products of disease. 



Chronic Gastric 
Catarrh. 

Occurs at any age. 

Pain slight and con- 
stant ; slightly in- 
creased by food ; gen- 
eral tenderness, not 
localized. 

Vomiting at times. 

Hemorrhage is rare and 
very slight. 



No fever. 
No cachexia. 
Kuns long course. Cur- 
able. 
No tumor. 
Constipation. 
No dropsy. 

Hydrochloric acid pres- 
ent. 

Symptoms of indiges- 
tion. 



Diagnosis. 

Gastric Ulcer. 

Young adults. 

Pain increased fifteen 
minutes after eating ; 
localized and tender 
to pressure ; radiates 
to back and chest. 

May or may not vomit. 
Profuse hemorrhage. 



No fever. 

No cachexia. 

Curable. May last five 

years. 
No tumor. 

May have constipation. 
No dropsy as a rule. 

Hydrochloric acid pres- 
ent. 
Slight indigestion. 



Gastric Cancer. 

After forty years. 

Constant boring, dull, or 
lancinating pain, not 
increased by food ; 
not tender to press- 
ure. 

Vomiting is a constant 
symptom. 

Frequent hemorrhage 
in small amounts. 
Coffee-ground ap- 
pearance. 

Attacks of fever. 

Marked cachexia. 

Fatal in one or two 
years. 

Usually tumor. 

Obstinate constipation. 

Usually dropsy. 

Absence of free hydro- 
chloric acid. 

Indigestion, flatulence, 
and marked acidity. 



In examining for tumor, lay patient on his abdomen. An- 
eurysm and other tumors have their peculiar characteristics. 



206 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Prognosis. — Bad, and all cases die in from six months to 
two years. 

Treatment. — Cundurango was recommended as a cure, bnt 
will only palliate. Resort to concentrated enema to sustain 
nutrition. Conium, Cannabis Indica, alcohol, ether, bromide 
of ethyl, and chloroform should be tried before resorting to 
opium. Give thepatient his ancesthetic, with instructions how 
to use it to relieve pain. Counteract acidity of stomach. 
Aloes or colocynth for constipation. Minute doses of carbolic 
acid or arsenite of copper and mix vomica to relieve vomiting. 
Charcoal, Fowler's solution, or mercury bichloride are good. 

Six surgical operations have been done to prolong life for 
a short time. Make patient as comfortable as possible. 



DILATATION OF THE STOMACH. 

Definition. — An increase in the normal capacity of the 
stomach, characterized by symptoms of indigestion, with at- 
tacks of vomiting at intervals of a few days. 

Etiology. — Pyloric obstruction. An acute form is due to 
over-distention by gas or liquid. 

Symptoms. — Marked symptoms of indigestion and gastric 
catarrh. Large eaters as a rule. Sense of fullness or weight 
in epigastrium. Vomiting every few days or oftener, and an 
immense quantity of partly digested food, taken days before, 
is thrown up, mixed with slime, mucus, or blood. Increased 
tympanites, and a peculiar sound on swallowing; also suc- 
cussion splash. Bowels constipated; patient emaciated; epi- 
gastric region prominent, and tumor felt at pylorus. Rum- 
bling of the bowels and symptoms of causative trouble. 

Pathology. — Walls of stomach are thickened or unusually 
thin. Pylorus is partially or entirely closed by a cicatrix, 



DISEASES OP THE STOMACH. 207 

thickened mucous membrane, or cancerous growth. Normal 
rugae are obliterated. Glands of stomach are atrophied or 
obliterated. Spores of yeast-plant are found in the stomach 
and vomit. Condition of chronic catarrh. 

Diagnosis. — When cause is evident, it is not difficult. Dis- 
tend the stomach with gas, and note percussion-area increased. 
Vomiting is characteristic. 

Prognosis. — Not encouraging. Die of causative disease or 
starvation. 

Treatment. — In acute dilatation, remove the liquid or gas 
at once by a stomach-tube. Frequent lavage with antiseptic 
solutions is indicated and gives most relief. Dry food in 
small quantities, predigested, and accompanied with an anti- 
ferment. Limit amount of liquids. Strychnine to tone the 
stomach. Galvanism or faradism. Charcoal, bismuth, and 
antiseptics all do good. Salines such as magnesii sulphas or 
Carlsbad salt. Surgical interference when indicated. 



GASTRIC HYPERTROPHY. 

Synonyms. — Gastric induration ; fibroid induration j cir- 
rhosis of the stomach. 

Description. — An organic disease of the stomach in which 
its walls are uniformly thickened and capacity diminished. 
Rarely seen. Coats are from one-half to an inch and a half 
thick, and capacity about four or five ounces. Causation and 
symptoms are obscure. A diffuse tumor is felt in the epigas- 
trium. Commonly affects pylorus and causes obstruction. 
Non-malignant. It may be a nucleus from which peritonitis 
will start. Ascites complicates. May have slight hemor- 
rhage, with coffee-ground vomit. No curative treatment is 
known. 



208 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

ILEMATEMESIS. 

Synonyms. — Gastrorrhagia ; gastric hemorrhage ; hemor- 
rhage from the stomach. 

Definition. — Hwmatemesis is a term used to designate the 
vomiting of blood, and is only a symptom of disease. 

Etiology. — Rupture of vessels ; venous congestion ; portal 
obstruction ; diseases of heart and liver ; varicose veins and 
aneurysms j hemorrhagic diathesis ; ulcers, cancer, corrosive 
poisons, foreign bodies, or direct injury. Anaemia, scurvy, 
malaria, yellow fever, vicarious menstruation, and numerous 
other causes. 

Symptoms. — Sense of pressure and constriction in the epi- 
gastrium ; dizziness, fluttering pulse, and sense of syncope 
when much blood is lest. Sudden rising causes syncope — 
often fatal. Vomiting of blood or contents of stomach. May 
be streaks of blood, bright red and clotted, or dark and like 
coffee-grounds. Blood may pass by bowels as black, tarry 
masses (melcena). 

Diagnosis. — Hcematemesis is preceded by faintness, pallor, 
fullness in epigastrium, vomiting of blood mixed with food, 
and black, tarry stools. 

ITcemoptysis, hemorrhage from lungs, begins suddenly with 
coughing up frothy blood, not blackened, and auscultatory 
symptoms. Bloody expectoration remains several days. 

Prognosis. — Death is not a frequent consequence, but may 
occur from hemorrhage or syncope. 

Treatment. — Treat the cause. Internally, for hemorrhage, 
give ice, tannic acid, alum-whey, sulphocarbolate of zinc, 
gr. v-x, acetate of lead, gr. i-iij, with opium, gr. 7, iron salts, 
dilute sulphuric acid, turpentine, or other astringents. Hypo- 
dermics of ergotine. Apply ice to the stomach. Give mor- 
phina hypodermically to quiet patient. Cannabis Indica will 



DISEASES OF THE STOMACH. 209 

answer. Treat syncope as indicated on page 212. Congestive 
hemorrhage requires active purgation. Over-activity of heart 
must be controlled by aconite. Allow no food except per 
rectum. Regulate bowels. Severe vomiting is controlled by 
tr. ipecacuanha?, fll ii-iv, bismuth, sulphocarbolate of zinc, or 
arsenite of copper. After-treatment is governed by causation. 

GASTRALGIA. 

Synonyms. — Cardialgia ; neuralgia of the stomach ; gastro- 
dynia ; stomachic colic. 

Definition. — A severe, paroxysmal pain in the stomach, due 
to hyperesthesia of its sensory nerves. 

Etiology. — Chlorosis, anaemia, hysteria, malaria, lithsemia, 
gout, acidity of stomach, cold drinks, worms, coffee or tea, 
articles of diet, or may be a true neuralgia. 

Symptoms. — Paroxysms of severe pain, independent of tak- 
ing food, lasting from a few minutes to hours, with intervals 
of rest. Fullness or pressure over epigastrium. Extremities 
cold ; abdomen tense ; and pain somewhat relieved by pressure. 
Diarrhoea and colic. It is easily induced by the emotions. 
Sympathetic pain under sternum is often felt. Reflex move- 
ments of the abdomen • cold perspiration ; tendency to vertigo ; 
and a slight cough. Vomiting causes relief. Urine is high- 
colored. 

Diagnosis. — Gastric ulcer has constant, localized pain, with 
vomiting of blood and catarrhal symptoms. Cancer has ca- 
chexia, tumor, and peculiar vomiting. Myalgic pain is less 
severe, and increased by pressure. Intercostal neuralgia pre- 
sents points of tenderness along the course of a nerve ; is uni- 
lateral, and shows no stomach symptoms. 

Prognosis — Not encouraging. Not fatal or dangerous to 
life. Sometimes curable. 



210 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Treatment. — Hysterical patients require mental impression, 
change of scene and occupation. Antispasmodics give tempo- 
rary relief, but will not reach the trouble. Leeches, electricity, 
and massage will do good as long as they are novel. Asafoet- 
ida sometimes cures. Never give narcotics or alcohol to these 
patients, as they easily contract the habit. When pain becomes 
severe, use anaesthetics. Treat any disorder from which it may 
arise. Regulate diet and bowels. Fowler's solution, long 
continued, answers nicely. 

DYSPEPSIA. 

Synonyms — Atonic dyspepsia; indigestion; pyrosis; 
heartburn ; nervous dyspepsia. 

Definition. — Dyspepsia is an indigestion of food without 
structural lesion. Term means primarily painful digestion. 

Etiology. — Improper mastication and ensalivation ; drink- 
ing water to moisten and wash down food; ice-water and 
ice-cream; improper diet and over-feeding; excessive use of 
coffee, tea, tobacco, and alcohol; lessened peristaltic action 
and exercise; hereditary; decreased or diluted gastric juice; 
anaemia, chlorosis, and fevers. 

Symptoms — Heaviness, weight, and fullness in epigastrium 
after eating, followed by belching wind and sour eructations 
(heartburn). Tongue is clean, breath is pure, and appetite 
uncertain. Marked nervous symptoms in some cases. Flatu- 
lence, and vomiting of sour and undigested food. Increased 
flow of saliva ; bowels constipated, or may have diarrhoea. 
There is a burning pain at the pit of the stomach after eating. 
Insomnia, drowsiness, headache, forgetfulness, palpitation of 
the heart, loss of flesh, and anaemia are characteristic symp- 
toms. There is a desire for condiments and spices. If allowed 
to continue, there are symptoms of catarrh. 



DISEASES OP THE STOMACH. 211 

Diagnosis. — True dyspepsia is not a common disorder, and, 
too frequently, cases of gastric catarrh are treated and diag- 
nosed for it. Structural lesions give pain when spices are taken, 
while dyspepsia does not. 

Prognosis. — Good. It is curable. 

Treatment. — Regulate diet and select blandest and most 
easily digested foods. Insist on proper mastication of food 
and forbid the use of drinks at meals. Forbid diet of tea 
and toast. Give malt-extract for indigestion of starches, 
pepsin for albumens, and pancreatin for fats. Eructations of 
fetid gas demand pancreatin. Forbid spices or condiments. 
If the structure of the stomach is impaired, give wine of rhu- 
barb, 3ss, with quinine, columbo, quassia, or nux vomica. In 
the aged, where there is lack -of peristaltic action, give nux 
vomica. Oxaluric dyspepsia demands alkaline salts, cold 
baths, and restriction of the diet. Tonics, in this condition, 
are injurious. Anwmia should receive iron or a natural chalyb- 
eate water. Hydrastine will compel a peptic gland to secrete. 
No remed}^ will settle nerves and restore their equilibrium 
better than capsicum. Rhubarb is an excellent remedy to 
tone the stomach. Ipecac, gr. -£§ to r&, is good. Tr. lobelue, 
gtt. v, will dry up secretion. Hydrochloric acid, dilute, gtt. x, 
with meals, or hydrogen peroxide prevents lactic-acid fer- 
mentation. Sodium bicarbonate, magnesii carbonas, charcoal, 
or lime-water will overcome acidity. Best hygiene, attention 
to diet and mastication, and as little medicine as possible con- 
stitutes the main line of treatment. 

STOMACHIC VERTIGO. 

Synonyms. — Syncope ; fainting ; vertigo ; giddiness ; light- 
headedness. 

Definition. — Vertigo is a transitory loss of consciousness, 



212 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

complete or partial, characterized by extreme pallor of the 
skin, a fullness in the head, sensation of falling, weakened 
heart-action, and sickness of the stomach. 

Etiology. — Over-eating, starvation, fright, fear, occupation j 
psychical causes ; heart, liver, stomach, or kidney disease ; gout, 
lithaemia, debility, over-work, defects of vision, laryngeal ver- 
tigo, constipation, and other causes. Loss of blood and shock. 
The two classes of vertigo are stomachic vertigo and cerebral 
vertigo. 

Symptoms. — Perspiration on the forehead ; great pallor of 
the skin j weakened heart-action j queer sensation in the head ; 
numbness j cloud rising before the eyes ; see sparks and hear 
noises j fear of falling ; thirst and a sensation of floating ; and, 
finally, a loss of consciousness accompanied by falling. An 
attack may last for one minute or longer. Dull, heavy head- 
ache, with symptoms of indigestion. 

Treatment. — Preventive. — Give assimilable diet and do not 
overload the stomach. Eat small amounts at frequent inter- 
vals ; forbid liquids and pastr} r . A little wine may do good, 
but you must watch habit. Regulate hygiene. Avoid all ex- 
citement or conditions that will cause an attack. In anaemia, 
give iron and arsenic. The best bitter and stimulant is tr. 
nucis vomicae. Aloes, gentian, or asafoetida for flatulence. Ni- 
tromuriatic acid for acidity, fifteen minutes before meals. 
Aromatic spirits of ammonia, stimulants, and rest in the re- 
cumbent position to avoid syncope. 

During tlie attack, elevate the extremities and lower the 
head, as fainting comes from an anaemia of the brain. Small 
whiff of ammonia. Cold to the face and chest. Hypodermic 
injections of alcohol, strychnina, or tonics. Artificial respi- 
ration. When due to loss of blood, use transfusion. Follow 
with tonics. 



DISEASES OF THE INTESTINES. 



DIARRHCEA. 

Diarrhoea is not a disease, but merely a symptom of local or 
constitutional disturbance, manifested by frequent abnormal 
passages from the bowels. Among the numerous causes 
might be enumerated: Psychical causes, such as fright, fegr, 
or anxiety. Reflex, from pregnancy or teething. Inflamma- 
tory, from ilio-colitis, typhlitis, proctitis, dysentery, cholera 
morbus, and cholera infantum. It also comes from heat, cold, 
and medicines. Accompanies such fevers as typhoid, typhus, 
yellow fever, cholera, acute rheumatism, and tuberculosis. It 
is present in gout, cancer, diabetes, anaemia, uraemia, leucaemia, 
and many other diseases. 

Stools ma}^ be watery, slimy, mucous, fatty, serous, bloody, 
bilious, mixed, feculent, membranous, lienteric, scybalous, 
diphtheritic, or purulent. 

As treatment, symptoms, and diagnosis depend on the cause, 
see appropriate headings — Ileo-colitis, Cholera Morbus, and 
Cholera Infantum. 

INTESTINAL CATARRH. 

Intestinal catarrh is usually limited to one part of the in- 
testinal canal, and rarely involves every portion at one time. 
The terms enteritis and intestinal catarrh are entirely too broad 
in their meaning and liable to confuse, even though public 

213 



214 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

use lias given them place. The terms will only be dealt with 
in a manner that will limit them to certain portions of the 
intestine involved. 

DUODENAL CATARRH. 

Synonyms. — Catarrh of the duodenum ; duodenitis. 

Definition. — An acute or chronic inflammation of the mu- 
cous membrane of the duodenum, which may extend to the 
gall-ducts and cause jaundice, constipation, severe pain, and 
symptoms of intestinal indigestion. 

Etiology. — Due to cold and errors in diet, such as too much 
fat; malarial toxaemia, germs, irritants of all kinds, and ex- 
tension from adjacent structures. 

Symptoms. — Painful digestion. Constipation — no diarrhoea. 
From the third to seventh day jaundice of varying degree ap- 
pears. Pain in the right hypochondrium and at the umbili- 
cus, with soreness aud tenderness on deep pressure. Liver is 
tender, and there may be hepatalgia. Great distress three 
hours after eating; flatulence and pain, especially marked 
after taking starches and fats. Breath bad and tongue coated. 
Fwces are white, putty-like, and offensive. Urine loaded with 
urates. Headache, vomiting, rise of temperature and pulse, 
and poor appetite. 

Pathology. — Duodenal mucous membrane is swollen, red, 
and inflamed. The ductus communis choledochus is occluded 
by the swollen membrane, or is inflamed itself, thus obstruct- 
ing flow of bile and causing jaundice. Pale stools mean an 
absence of bile. Bile is an antiseptic, and when absent there 
is intestinal indigestion with flatulence. Duodenal ulcers may 
be found. 

Diagnosis. — Gastric catarrh has peculiar pain and nausea 
soon after eating. Pain in duodenitis is three hours after 



DISEASES OF THE INTESTINES. 215 

eating, and associated with jaundice. Hepatic colic is parox- 
ysmal and more severe. Hepatalgia begins suddenly, and 
leaves as soon without sequelae. 

Prognosis. — Good. It lasts two to three weeks. May be- 
come chronic. 

Treatment. — Diet. — Avoid starches, fats, alcohol, and stimu- 
lants. Give predigested albumens and skimmed milk, in small 
quantities. No pulps of meat or any irritant food. Very 
weak coffee with skimmed milk may be allowed. White of 
egg or game. A large injection of cold water, repeated, will re- 
lieve congestive symptoms best. It also cleanses the bowel 
of faecal matter. Alkalies, phosphate of soda, Rochelle salts, 
and taraxacum are recommended. Give three to five grains 
of bismuth subnitrate every hour or two. Place mustard 
poultices or a fly-blister over the painful spots to relieve pain. 
May resort to belladonna, hyoscyamus, Cannabis Indica, or 
opium for pain. From the first, give ox-gall, gr. iii-v, to keep 
the intestines aseptic, aid digestion, and supply deficiency of 
bile. Malarial toxaemia indicates quinine, per rectum, gr. xx- 
xxx, daily. If ulceration is suspected, feed per rectum, and 
administer silver salts, sulphocarbolate of zinc, or other anti- 
septics. 

TYPHLITIS. 

Synonyms. — Catarrh or inflammation of the caecum. 

Definition. — An inflammation of the mucous membrane of 
the caecum, which may involve the colon and appendix vermi- 
formis (appendicitis), accompanied by fever, local tenderness, 
constipation, and symptoms of peritonitis. 

Etiology. — Lodgment of foreign bodies such as seeds, but- 
tons, and faeces. Direct injury, extension, and exposure to 
cold. 



216 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Symptoms. — Uneasiness, pain, tenderness on pressure in 
right iliac fossa and along the ascending colon, with some 
prominence. Legs flexed on abdomen ; obstinate constipation ; 
dyspnoea ; malaise ; high fever ; coated tongue ; anorexia ; vom- 
iting ; great depression ; cold, clammy skin ; and, at times, all 
symptoms of peritonitis. A tumor that feels like hard links 
of sausage, due to impacted fasces, is felt in the right iliac 
region. Great peristaltic action and vomiting of fcecal matter. 
May have a slight diarrhoea from the irritating impaction. 
Perforation is indicated by sudden collapse, high fever, and 
severe peritonitis. 

Diagnosis. — Made from the severe localized pain in the 
right iliac fossa ; peculiar sausage- shaped tumor ; high fever 
and constipation. 

Prognosis. — Lasts one week or more, and usually recover. 

Treatment. — Avoid active purgation. Rest in bed. Sul- 
phate of magnesium, gr. xx, with opium, to liquefy the stools, and 
avoid increased peristaltic action resulting from cathartics. If 
inflammation is not severe, rectal injections of water as hot as 
can be borne, every four hours, act as poultices and remove 
impactions. Give liquid foods and milk. Relieve abdominal 
tension by supporting the legs with pillows. Laparotomy is 
often advisable to remove impactions and sloughing tissue. 
Vomiting is hard to control, but a hypodermic of morphina or 
opium internally will relieve it and pain. Prevent impaction 
b}- injections ; use good hygiene, and recovery usually follows. 

PERITYPHLITIS. 

Description. — An- inflammation of the loose areolar tissue 
around the caecum, closely related to typhlitis and due to it 
or direct injury. May occur in typhoid or typhus fever. The 
symptoms are those of peritonitis and typhlitis. Fever, eon- 



DISEASES OF THE INTESTINES. 217 

stipation, and tumor in right iliac region, with tenderness and 
severe pain. The exudation is absorbed or suppurates. Sup- 
puration is preceded by chills and fever. Abscess will open 
into the bowel, peritoneum, or on the skin. Attacks fre- 
quently recur. 

Treatment. — In the very start, treat same as in typhlitis, 
with hot poultices, cold compress, or leeches, and small doses 
of magnesium sulphate, with morphina to relieve pain. Sul- 
phide of calcium, gr. n,-, every three hours, will often prevent 
suppuration. Surgical treatment is now recognized as a cura- 
tive means, and when abscess is found or suspected, operative 
interference is advisable. Aspiration may be done, but lapa- 
rotomy is most certain. Cleanse abscess cavity with peroxide 
of hydrogen or pyoctanin (ten percent.), and give tonic treat- 
ment. No solid foods. Liquid and nourishing diet. 



PROCTITIS. 

Synonyms. — Catarrh of the rectum j mild dysentery ; " rec- 
titis." 

Definition. — An inflammation of the rectum, recognized by 
a burning pain, with frequent desire to go to stool, marked 
tenesmus, and passage of mucus, blood, and scybala. 

Etiology. — Most common in women. Due to constipation ; 
frequent rectal injections ; hemorrhoids ; foreign bodies ; press- 
ure of a retroverted uterus or tumor ; catching cold or sitting 
on cold, damp substances ; habitual use of aloes ; cirrhosis of 
the liver. 

Symptoms. — A burning, uneasy sensation in the rectum, with 
pain on defecation. The discharges consist of mucus mixed 
with blood or pus and scybalous matter. Great tenesmus ; 
frequent and constant desire to go to stool, with passage of small 



218 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

amounts at a time. Nausea, anxiety, and, in some cases, fever. 
Colon is usually impacted. Headache, prostration, and ex- 
treme muscular soreness. Bladder is irritable and there is 
often retention. 

Chronic proctitis presents the same symptoms, not so well 
marked. Stools are loose, offensive, and soon become puru- 
lent. Ulcers form and sloughs are passed. 

Pathology. — That of inflammation in other parts of the 
intestine. Large ulcers are formed. 

Diagnosis. — Can hardly be mistaken, if symptoms are noted. 

Prognosis. — Mild cases recover in one week or less. Severe 
cases may become chronic ; cause periproctitis, abscess of the 
liver, or thrombosis of the hemorrhoidal veins. 

Treatment. — In mild cases, with little strangury or diar- 
rhoea, give small doses of castor-oil, with a few drops of lau- 
danum. 

Olei ricini f 3ij. 

Tr. opii "1 ij. 

Aquae menthae pip n L i-iij. 

Sacehari q. s. 

M. Signa. (rive every three hours. 

Careful injections of a pint of hot water or flaxseed-tea re- 
lieve greatly. Nitrate of silver, gr. xx, to eight ounces of flax- 
seed-tea, may be used as an injection in severe cases. Impac- 
tion and fever indicate a mild saline. 

R 

Magnesii sulphatis gr. xxx. 

Acidi sulplmrici aromatcii ^l x. 

Tr. opii camphoratae Tl l x. 

Aquae menthae pip f 3 j. 

M. Signa. Give every three or four hours. 



DISEASES OF THE INTESTINES. 219 

Rest in bed and light diet that will leave no residue. Sup- 
positories containing oxide of silver, pyoctanin, glycozone, or 
cocaine are recommended. Small doses of calomel and ipecac 
often give good results. Correct a misplaced uterus ; relieve 
hemorrhoids ; and regulate habits. Treat ulcers surgically. 
The best application is pure nitric acid. Avoid large doses of 
opium in acute proctitis, as they are objectionable. 

PERIPROCTITIS. 

Description. — An inflammation of the cellular tissue sur- 
rounding the rectum, arising from proctitis, direct injury, or 
tuberculosis. Great pain attends, and an exudation occurs 
which is absorbed or suppurates, giving rise to a fistula. A 
hard or soft tumor is felt in the perineum. Patient cannot 
sit down, and has great pain at stools. Stricture of the rectum 
may result. 

Treatment. — Open abscess as soon as found, and treat sur- 
gically, observing the modern rules of antisepsis. Give tonic 
treatment and nourish the patient with appropriate diet. 

CHOLERA MORBUS. 

Synonyms. — English cholera ; cholera nostras ; bilious 
cholera. 

Definition. — A severe catarrh of the mucous membrane of 
the stomach and bowels, coming on suddenly with violent 
vomiting, diarrhoea, cramps, and great prostration. 

Etiology. — A disease principally of spring, summer, and 
fall. Unwholesome food, catching cold, improper hygiene. 
Said to be due to germs in milk, water, and food. 

Symptoms. — Sudden in onset, usually at night. Begins 
with a chill, followed by severe colic, vomiting, and purging. 
Diarrhoea. Stools are first formed and soon become like rice- 



220 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

water; large, free evacuations ; body shrinks away; voice be- 
comes husky ; patient goes into collapse ; breath is cold and 
tongue dry. Violent cramps in the muscles of the arms and 
calves of the legs. Pulse is feeble ; great anxiety and thirst. 
All food is vomited. Muscles may rarely rupture from con- 
traction. 

Pathology. — Blood is thick and dark, and the serous mem- 
branes are dry. Muscles are granular. Muscular cramps are 
due to lessened fluidity of the blood. Gastro-intestinal mu- 
cous membrane is inflamed, sometimes ulcerated, and glands 
enlarged. Cases may occur in which no lesion is found. A 
bacillus, similar to that found in cholera, is claimed to be 
present. 

Diagnosis. — Arsenical and other mineral poisons simulate 
cholera morbus and can only be diagnosed by the history or 
post-mortem. Asiatic cholera is epidemic, is more fatal, and 
presents the cholera bacillus of Koch. 

Prognosis. — Rarely fatal in this country. Lasts from a 
few hours to one day. Dr. Janhaa says that "in cases of 
healthy persons, in this country, cholera morbus is never fatal." 

Treatment. — The first indication is to relieve pain and 
cramps. A hypodermic of morphinae sulphas, gr. J to ■§-, with 
atrophias sulphas, gr. T ^o- Household remedies are ginger, 
mustard, pepper, volatile oils, spices, brandy, ammonia, or 
laudanum. (See Colic, p. 209.) The Hindus use what they 
term a hot treatment. 

ft 

Olei cajupiti f 3 j. 

Tr. capsici f 3 iv. 

Tr. camphor® f 3ij. 

Chloroformi f 3 j. 

iEtheris fortioris q. s. ad. ffij. 

M. Signa. One teaspoonful every half-hour in its purity, 

until relieved. Do not add or follow with water. 



DISEASES OP THE INTESTINES. 221 

This is a hot close and brings tears to the eyes, but will 
always relieve if given from the first. Wrap patient in good 
hot blankets and apply hot water or mustard over the seat of 
pain. When due to cold, give hot drinks. Small doses of 
arsenite of copper, every ten minutes, will relieve cramps. 
Da Costa recommends inunctions of chloral for muscular 
cramps. 

Vomiting and Diarrhoea. — Nothing will relieve better than 
small doses of calomel and pulv. ipecac, (gr. T o~o)> every two 
hours. Cupric arsenite also controls it. A most reliable and 
efficient combination for vomiting and purging is : 

Zinci sulphocarbolatis gr. ss-ij. 

Lactopepsin gr. i-ij. 

Bismuthi subnitratis gr. i-v. 

Misce. Fiat pulv. No. 1. Signa. Every one or two hours 
until symptoms are checked. If first dose is vomited, persist 
every few minutes until one will be retained. 

Salol, iodine, salicylic acid, and a host of other antiseptic 
and antispasmodic remedies are recommended. A large dose 
of castor-oil or aromatic syrup of rhubarb will often relieve, 
when the cause is error in diet. Always remember that in 
diarrhoea elimination is the main principle, and all treatment 
must be preceded by a saline cathartic, calomel or castor-oil, 
and followed with intestinal antiseptics. 

A broad flannel band around the abdomen will often prevent 
an attack. Rest in bed; care in diet and tonic treatment 
when the attack has passed. Acid drinks and pellets of ice 
relieve thirst. (See Diarrhoea, p. 223.) 



222 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

CHOLERA INFANTUM. 

Synonyms. — Infantile cholera • infantile summer com- 
plaint. 

Definition. — An acnte catarrh of the mucous membrane of 
the stomach and intestines of young children, with marked 
diarrhoea, vomiting, nervous manifestations, and fever. 

Etiology. — Teething, improper diet, bad hygiene, heat, and 
disease germs. Occurs during the first two years of life in 
summer-time. Epidemic. Doubtful if it is contagious. 

Symptoms. — The child may be feverish, irritable, and have 
a slight diarrhoea for weeks before the onset ; or the attack 
may come suddenly with vomiting, retelling, colicky pains, a clear, 
serous, odorless, or greenish diarrhoea. Stools are frequent, and 
number from ten to forty in a day. Body becomes shrunken 
in a few hours j mouth and eyes are half open, and there is a 
vacant stare. Red spots on the cheek and soreness along the 
colon. Respiration is shallow. Fever, burning heat in the 
forehead and epigastrium, and a great desire for drink. 
Tongue is dry and brown, and pupils contracted. Shin is cold 
and clammy, and patient goes into collapse and dies, or slowly 
recovers. Convulsions often occur. 

Pathology. — That of any inflammation, and may involve 
the stomach, intestines, or both. The constitutional symptoms 
are due to absorption of ptomaines from the intestinal canal, 
where they are produced by germs. Kidneys are congested 
and the blood is dark and thick. 

Diagnosis. — Ilio-colitis is gradual in onset, and should not 
be confounded with the sudden onset of cholera infantum. 

Prognosis. — If taken at once, it is good ; later, it is more 
fatal. It Mils more children than any other disease. 

Treatment. — Preventive, — See to hygienic surroundings. 
Keep the child cool, and allow cold drinks in moderation. 



DISEASES OP THE INTESTINES. 223 

Dress loosely, always with wool next the sMn. Give plenty of 
fresh air ; and keep it cool during the heat of the day. 
Sterilized milk must be insisted upon in artificially fed chil- 
dren. Dr. Hirst recommends the following- formula, which he 
lias modified from other formulae : " For a two-ounce bottle, 
take of cream five ounces and milk two and one-half ounces j 
put in a skillet, and digest with two and one-half grains of 
pancreatin and sodium bicarbonate, five grains. Put in each 
bottle six drams of the mixture, and add ten drams of sugar 
solution (one ounce to the pint)." Another formula, that i? 
like mother's milk, is : 

ft 

Cream f 3iv. 

Cow's milk f 3 ij. 

Milk-sugar gr. 1. 

Water f 1 j. 

Thoroughly sterilize, then add 

Lime-water f 3ij. M 

When diarrhoea is simple, give small doses of calomel or 
syr. rhei aromaticus, with a few grains of sodium bicarbonate 
or potassium carbonate, every two or three hours. If this 
fails, give the sulphocarbolate of zinc, with bismuth and pepsin 
(see p. 221), as it destroys germs, stops vomiting and pain, and 
relieves fever by its antiseptic and antispasmodic action. A 
favorite formula after elimination has been complete is : 

ft 

Bismuth! subnitratis 3 j. 

Glycerol acidi carbolici tn. xvj. 

Tr. cardamomi comp. 

Spts. chlorof ormi aa. f 3 iv. 

Aquae menthae pip q. s. ad. f 1 ij. 

M. Signa. One-half to one teaspoonful in water every two 

or three hours. Shake before taking. (B. Reed.) 



224 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

If diarrhoea still proves obstinate, use a free rectal injec- 
tion of sulphocarbolate of zinc, gr. x to f § ij of warm water, 
as the poisons are active in the lower bowel and cannot be 
reached by the month. When the child is comatose, hard to 
arouse, feverish, and threatened with convulsions, place its 
whole body in a tepid-water hath (98° to 101° F.), and apply 
cold to the head and mustard to the back of its neck. This 
will arouse it and afford opportunity to give medicines. After 
a bath of this kind, wrap the child in hot blankets and keep 
the head cool. Stimulate with hot coffee or brandy if neces- 
sary. (For other treatment of diarrhoea, see p. 221.) Diet 
should be the mildest. G-ive whites of eggs, in water, with 
pepsin ; rice-water, to which may be added artificial foods. In 
this condition opium must be used with great caution, for 
its use usually means death in the severe forms. The cardinal 
points in treatment are elimination, diet, and intestinal anti- 
sepsis. 

ILEO-COLITIS. 

Synonyms. — "Summer diarrhoea"; inflammatory diar- 
rhoea ; improperly called catarrhal enteritis. 

Definition. — A catarrhal inflammation, acute or chronic, 
limited to the lower part of the ileum and portion of the colon, 
with diarrhoea, vomiting, pain, slight febrile reaction, and 
rapid depression. 

Etiology — Heat, cold, bad milk, and improper diet; bad 
hygiene and over-crowding. A disease principally of city, 
hand-fed babies under two years of age. 

Symptoms — Acute. — Discomfort about the belly, with diar- 
rhoea. There is purging of a sour, acid, curdy-like material, 
at times mixed with blood. Later, it is watery or greenish, 
and smells very bad. Vomiting of acid, curdy masses. There 
are from ten to twenty stools daily. Depression, weakness, 



DISEASES OF THE INTESTINES. 225 

red tongue, skin dry, urine scanty, pulse feeble, and tempera- 
ture may reach 104° F. Dysenteric symptoms may supervene. 
Griping pains. Nephritis is a complication. Child may be- 
come comatose, pupils are sluggish, skin dark, involuntary 
stools, convulsions, and death. Spurious hydrocephalus, from 
thrombosis, may occur. Prolapse of the rectum comes from 
straining at stool. 

Chronic. — Follows the acute. Stools are not so frequent, 
but are offensive, thin, and contain mucus, pus, or serum. 
Skin is pale and flabby. Indigestion and vomiting. Acute at- 
tacks occur. It may last for months. Little or no pain. 
Ulceration is indicated by hemorrhage or dark clots. Flatu- 
lence, rapid exhaustion, and finally death or recovery. 

Pathology. — Acute. — Mucous membrane of the ileum and 
colon is thickened, red, inflamed, and coated with mucus and 
epithelial cells. Pyer's glands are swollen. Mesenteric and 
intestinal glands are swollen and dark. 

Chronic. — Membrane is dark red or gray, with enlarged 
follicles. A false membrane sometimes exists. Small, dark 
patches are seen, and ulcers at the seat of the follicles. Kid- 
ney is involved. Invagination often occurs. 

Diagnosis. — Easily made from typhoid fever and tuberculous 
ulceration of the bowels. 

Prognosis. — Not very good, in large cities ; but where 
proper precautions can be taken and treatment carried out, 
it is favorable. 

Treatment. — Absolute rest in a cool room during the heat of 
the day. Good, fresh, pure air of the country, mountains, or 
sea-shore. Clothe with flannel. Diet must be regulated, and 
nothing but mother's milk, or, if hand-fed, nothing but whey, 
with a small amount of prepared food, can be given. Sterilized 
milk may be given. (See p. 223.) Koumyss is often of ad- 
vantage as a food. Fever and stupor require tepid baths — not 



226 A SYNOPSIS OP THE PRACTICE OF MEDICINE. 

antipyretics, as they are too depressing. If the case is seen 
early, give calomel in one-tenth-grain doses, castor-oil or 
rheum, with soda, to cleanse the bowel. Follow this with 
sulphocarbolate of zinc, bismuth, and pepsin. Diarrhoea is 
treated as indicated on pages 221 and 223. Bichloride of 
mercury and salicylate of bismuth have their advocates. 
Stimulate as much and as often as is necessary. One one- 
hundredth grain doses of triturated calomel and ipecac, every 
one or two hours, are excellent. 

In the chronic form, regulate diet ; give astringents, and 
tonics of quinine, iron, and cod-liver oil. When the lower 
bowel becomes involved, use injections of the silver salts. 
Oxide of silver, gr. -J to i, in pill form for ulceration. 

ACUTE DYSENTERY. 

Synonyms. — Bloody flux ; ulcerative colitis ; colitis. 

Definition. — An acute, sporadic, endemic or epidemic, infec- 
tious inflammation of the mucous membrane of the colon, with 
tenesmus, frequent desire to go to stool, and passage of scyb- 
alous masses, mucus, blood, and serum. 

Etiology. — Foul air, impure water, bad drainage and food, 
atmospheric changes from heat to cold. Epidemic in armies, 
prisons, and cities. Endemic in the tropics. It is not conta- 
gious, but is infectious. The varieties are acute catarrhal, ul- 
cerative, croupous, diphtheritic or gangrenous dysentery. 
Primary cause is a germ whose identity is unknown. 

Symptoms. — Sometimes there is a protracted diarrhoea 
which precedes the onset. Onset with a chill, followed by 
slight fever. Tenderness along the colon on pressure. Rum- 
bling of the bowels, and colicky pains (tormina) at the umbilicus. 
A burning, weighty feeling at the anus, and constant desire to go 
to stool, not relieved by defecation and violent straining (tenes- 



DISEASES OF THE INTESTINES. 227 

mas). Stools are small in amount and mixed with blood, 
mucus, or pus, and are highly offensive, with here and there 
a small faecal mass. Vomiting is not a constant symptom. 
When the inflammation subsides, large faecal masses are 
passed, showing a condition of constipation. 

At times the stools are dark, slimy, and putrid, with pieces 
of sloughed mucous membrane, giving rise to the term diph- 
theritic or gangrenous dysentery. Vomiting, hiccup, and great 
depression ; tenesmus, cold skin, and weak heart. Gangrenous 
dysentery is most common in armies, and is attended with 
great prostration. 

Pathology. — Catarrhal Dysentery. — Mucous membrane of 
the colon is swollen, infiltrated, covered with muco-pus; en- 
larged glands, softened patches, or even desquamated epithe- 
lium, leaving small ulcers or cicatrices. Probably due to a 
germ. 

Diphtheritic Dysentery. — Ulcers with thick, irregular base, 
more or less gangrenous, with a mucous or false membranous 
coating like that of diphtheria, forming a cast of the bowel. 
Large cicatrices may remain, causing intestinal obstruction. 

Gangrenous dysentery is an aggravated form, with extensive 
destruction of tissue, involving one or all three coats and 
causing perforation. 

Diagnosis. — Inflammation of the small intestine is accom- 
panied with profuse diarrhoea, without tenesmus and rectal 
irritation. Proctitis is not so acute ; stools are not so offen- 
sive ; and is shorter in duration. Typhoid fever has peculiar 
temperature, eruption, and other symptoms. 

Prognosis. — Recovery takes place in one or two weeks, in 
mild cases. May result in stricture of the bowel, chronic 
form, perforation with peritonitis, abscess, or death. 

Treatment. — Preventive. — During epidemics, provide the 
best drainage, food, and hygiene. Drink only boiled water 



228 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

and thoroughly cooked foods. Eat no fruits. Wear flannel 
round the abdomen, and avoid exposure to heat. Keep bowels 
regular, and disinfect stools of patients. During the attack, 
give only such nourishing food as will digest in the stomach 
and leave no residue. If seen early and the stools contain 
scybala, give castor-oil, f 3 ss-j, with tr. opii, gtt. v-x, once 
daily, to clear the bowels of faeces. Cleanse the bowel with 
one pint of hot water, and inject silver nitrate, 3 ss-j, with 
hot water, Oj, once or twice daily. 

Internally, give pulvis ipecac rad., gr. xxx-xl, in the smallest 
quantity of hot water possible, and make the patient lie quietly 
in bed to prevent vomiting. Repeat at once if vomited, and 
persist until it is retained. Put a hot flaxseed poultice over 
the abdomen. Every two hours give sulphocarbolate of zinc, 
gr. iv-v. Salol, gr. iij, ma}^ be given. Aconite, in small doses, 
is a general treatment in India. A combination of tr. Canna- 
bis Indica and tr. hyoscyamus is recommended. Naphthalin, 
gr. i-v, every two hours, with castor-oil and opium. Bismuth, 
Fowler's solution, and silver salts all do good. When these 
forms of treatment fail, give full doses of opium — these are 
dangerous, but often curative. Frequently cleanse the bowel 
by hot or cold injections. Give tonics during the whole dis- 
ease. In gangrenous or diphtheritic dysentery, use antiseptic 
injections or diluted peroxide of hydrogen, with tonic treat- 
ment and turpentine internally. Suppositories of opium and 
oxide of silver are often beneficial. 

CHRONIC DYSENTERY. 

Description. — Usually comes from the acute. The stools 
number from two to twenty daily, are offensive, and contain 
mucus, pus or blood, and scybalous masses. Stools vary 
from day to day. Appetite is capricious, tongue red and 



DISEASES OF THE INTESTINES. 229 

glazed, and patient emaciates. Abscess of the liver is common. 
Death may be due to pneumonia, phthisis, Bright's disease, 
lardaceous disease of viscera, faecal abscess, or peritonitis. 
The disease is very intractable. There is a hectic fever j ab- 
domen is sunken and tender ; tenesmus and general debility. 
Post-mortem shows a thickened, ulcerated or cicatrized mu- 
cous membrane. If recovery ensues, the bowels are always 
very susceptible to changes or relapses. 

Treatment. — Change of climate, best hygiene, and woolen 
underclothing. Milk and foods that digest in the stomach 
without residue remaining. Pulv. ipecac, gr. ij, in pill form, 
ter die, often checks symptoms. Astringents and antiseptics. 
Sulphocarbolate of zinc, salol, arsenite of copper, and other 
salts have their advocates. Monsel's solution, trt vj the sul- 
phate or nitrate of iron. Rectal injections of nitrate of silver. 
Opium, bismuth salicylate, and silver oxide, combined, as a 
suppository, are good. Terebene or turpentine with opium. 
Counter-irritation. 

ULCERS OF THE INTESTINE. 

Ulceration may occur in any part of the intestine, and is 
simply a condition and not a disease of itself. It is symptomatic 
of such conditions as typhoid fever, tuberculosis, cancer, dys- 
entery, ilio-colitis, and other inflammatory conditions. It is 
most common in the ilium, and its main symptom is obstinate 
diarrhoea. (For treatment and particulars, see Causative 
Diseases.) 

CANCER OF THE INTESTINE. 

Cancer of the intestine is rare, and occurs after forty years 
of age. Scirrhous is most common, then the colloid. There is 
a dull, heavy, steady, or sharp periodical pain, with a tend- 



230 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

eney to diarrhoea. Salivation, anaemia, cachexia, and emacia- 
tion. Death is the ultimate result. Treatment is palliative, 
and consists of opium and injections of hot water with as- 
tringents. 

INTESTINAL OBSTRUCTION. 

Definition. — Obstruction of the bowels is an occlusion, 
partial or complete, of any portion of the intestinal canal, 
which retards or prevents the normal passage of faecal matter. 

Etiology. — Constipation ; stricture ; congenital or acquired ; 
strangulated hernia j compression from tumors ; torsion j im- 
paction of foreign bodies such as gall-stones ; intussusception j 
and peritoneal adhesions. 

Symptoms. — Acute. — Intense abdominal pain at the umbili- 
cus, coming on suddenly, continuing, and increased by pressure. 
Vomiting of food, then bile, and finally faecal matter if the ob- 
struction is low down. Vomiting is persistent, and no food 
can be taken. Abdomen is tense, swollen, and tympanitic ; 
great rumbling of the intestines. Constipation is marked, and 
is not relieved by ordinary methods. If obstruction is high 
up, faeces may pass from the lower bowel. 

Intussusception causes a bloody, mucous passage, and, at 
times, a portion of sloughed gut may be ejected. Tumor in 
the region of invagination. Breath is bad, eyes sunken', and 
collapse comes early. Temperature falls ; pulse is weak ; 
great thirst ; tongue dry ; peritonitis ; and death in three to 
seven days. 

Chronic obstruction is due to cancers, constipation, adhe- 
sions, tumors, and inflammatory processes. Constipation is 
irregular, and can be overcome at first. Vomiting takes place 
at intervals, but is not faecal. Abdomen is distended, and 
some pain is present. Gradually the symptoms become more 



DISEASES OF THE INTESTINES. 231 

severe 5 constipation is marked; faecal vomiting; pain is 
severe ; and a regular acute attack follows. 

Pathology. — Intussusception (invagination) is a slipping of 
one part of the gut into another, like the finger of a glove. 
The most common form is the ilio-ccecal, then the ilio-colic. 
Inflammation ensues, adhesions form, the invaginated part of 
the gut sloughs away, and there is resolution or death. Pa- 
thology of other affections is the same as the cause. 

Diagnosis. — Adhesions have a history of previous perito- 
nitis. Constipation has its history of slow onset. Impacted gall- 
stones follow hepatic colic. Hernia is readily diagnosed. In- 
tussusception is of sudden onset, in male children mostly, with 
vomiting, spasmodic pain, bloody stools, tumor, and passage 
of sloughed gut. Fwcal vomiting indicates an obstruction low 
down. In general, pain is due to colic and peritonitis. 

Prognosis. — Depends on the form, but is usually bad. 

Treatment. — Never administer purgatives. Give opium to 
quiet pain and peristaltic action. In the acute form, hernia 
must be reduced by manipulation or surgical measures. In- 
tussusception, in its first stages, may be relieved by gentle 
manipulation ; inflation of the intestines by injections of gas ; 
or distention with a water enema, as large as can be given. 
Failing in this, laparotomy must be done. Adhesions, impacted 
gall-stones, and cancers require laparotomy and resection 
of the gut. Constipation (see page 233). If food cannot 
be retained, give alimentation per rectum. Stimulate and 
support. Intestinal antisepsis sometimes overcomes tympany. 
Aspiration is also used to relieve tympany. 

INTESTINAL HEMORRHAGE. 

Description. — Hemorrhage is merely a symptom of a diseased 
condition, and may come from any part of the intestinal canal. 



232 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Its principal causes are ulcers of typhoid, dysentery, and other 
conditions. Cancer, hemorrhoids, enlarged uterus, obstruc- 
tion of the lungs or heart, cirrhosis, scurvy, and purpura all 
give rise to it. Hemorrhage may be arterial, venous, or 
capillary. Blood from the small intestines is black, tarry, 
and mixed with faeces. From the lower bowel, it precedes 
or follows a stool, and is not blackened or mixed with fasces. 
It may be in a stream, clots, drops, or merely streaks. Treat- 
ment is considered in connection with the causative troubles. 

ENTERALGIA. 

Synonyms. — Intestinal colic ; tormina ; " cramp colic " ; in- 
testinal neuralgia. 

Definition. — An acute, paroxysmal pain in the region of 
the umbilicus, slightly relieved by pressure, due to an irrita- 
tion of the sensory nerves, with spasmodic contraction of the 
intestinal muscle, and not accompanied by fever. 

Etiology. — Improper diet, such as crabs, unripe fruit, spoiled 
meats and fish ; great changes of heat or cold ; neuralgia, hys- 
teria, hypochondriasis, intestinal indigestion ; copper or lead 
poisoning; malarial or specific infection. 

Symptoms. — Patient is found in great agony, with the 
limbs drawn up, pressing his abdomen ; features pinched ; 
skin cold ; a cold perspiration ; and a grinding, twisting, cutting 
pain in the umbilical region. Nausea, vomiting, and a desire 
to go to stool. Great anxiety. Pain may last for a few 
hours or a day, and leaves the abdomen tender and sore. No 
fever. Abdomen is tense and often retracted ; tympany and 
borborygmus. The paroxysm may come on suddenly or 
slowly. Lead colic comes on in connection with a history 
of lead-poisoning. 

Diagnosis. — Hepatic, renal, uterine, and ovarian colic have 



DISEASES OF THE INTESTINES. 233 

their peculiar localized symptoms. Inflammatory troubles have 
fever, while ordinary colic has not. Gastralgia is localized to 
the stomach and is relieved by vomiting. 

Treatment. — For the paroxysm : A hypodermic of mor- 
pliinaB sulphas, gr. \ to -g-, and atropinge sulphas, gr. T |-o, is most 
certain. May give morphina, gr. \ to -J-, in a spoonful of hot 
water, for speedy relief. Chlorodyne, chloranodyne, or Hoff- 
man's anodyne. Volatile oils, brandy, chloroform or ether, 
or arsenite of copper all serve a good purpose to relieve pain. 
Applications of mustard, hot poultices, or dry heat over the 
abdomen are useful. The next indication is to eliminate. 
Give a large dose of castor-oil or aromatic syrup of rhubarb. 
The best combination is : 

Hydrargyri chloridi mitis gr. iij. 

Sodii bicarbonatis 3 j. 

Sacchari lactis 3 j. 

M. Fiat pulv. No. 10. Signa. One every hour. 

If they do not act freely when five are taken, give a half- 
bottle of liquid citrate of magnesia. Follow with light diet 
and tonics. 

Lead colic demands morphina, magnesium sulphate, and 
potassium iodide. (For other treatment of colic, see Cramp, 
p. 220.) 

CONSTIPATION. 

Synonym . — Costiveness. 

Definition. — A term used to denote a deficiency or absence 
of the normal passage from the bowels. 

Etiology. — Indigestion, torpid liver, articles of diet, lack of 
proper tone, and innervation of the intestinal muscle, causing 
lessened peristaltic action. Habit is a common cause from 
neglect. Symptomatic of lead-poisoning, obstruction, malaria, 



234 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

diseases of the liver, stomach, and bowels. Most common in 
women. 

Symptoms. — Bowels are never moved except cathartics 
are taken, and then only once in every three days or a week. 
Normally, a person should have at least one large free passage 
every day. Besides these symptoms they complain of head- 
ache, giddiness, sluggish mental activity, lack of appetite, 
digestive disturbances, and sallow complexion. Palpitation 
of the heart, cold extremities, and great straining on defeca- 
tion. Stools are hard and lumpy. 

Treatment. — Seek for the cause and remove it. If due to 
retroverted uterus, replace it. Impaction of the colon requires 
hot- water injections and mechanical means. Correct diet 
and habits, and insist on a regular hour in which to go to stool 
every day. Instruct patients to hold the gases in the bowel and 
not to pass them off every time they desire it, as they keep 
the bowels distended and aid in the passage of faecal matter. 
A glass of ice-cold or hot water, with a little salt in it, before 
breakfast, answers in mild cases. Massage or kneading the 
abdomen, and exercise, constitute valuable means of relief. 
Mild galvanism or faradism, applied along the course of the 
colon or by a negative rectal electrode, will cause passages in 
the most obstinate and chronic cases. Cascara sagrada and 
other drugs answer nicely. Calomel in large doses, gr. v-x, 
or in small doses, gr. - f V to J, in tablet triturates, every two 
hours. 

When the stools are dry, give small doses of magnesium 
sulphate, or 

ft 

Ext. nucis vomicae gr. 1/4. 

Ext. hydrastis gr. j. 

Pulv. rhei gr. j. 

Misce. Fiat pil. No. 1. Signa. One night and morning. 



DISEASES OF THE INTESTINES. 235 

In old chronic cases, the best results come from : 

Ext. aloini purif gr. x. 

Ext. micis vomica? gr. x. 

Ext. belladonna? gr. iv. 

Oleoresinee capsici g"r. ij. 

Misce. Fiat pil. No. 20. Signa. One pill thrice daily. As 
soon as two passages occur in one day, order one-half pill 
and so diminish until the habit of constipation is broken up. 
(Waugh.) 

Other conditions have their appropriate forms of treatment 
aud are considered with the causative trouble. 

INTESTINAL WORMS. 

Varieties. — Tcenia solium; Botlirioceplialus latus; Taenia sag- 
inata; Tcenia mediocanellata — all varieties of the tapeworm. 
Ascaris lumbr 'acoides, or round- worm. Oxyuris vermicular is, 
or seat-worm. Triclioceplialus disbar. Anchylostomum duo- 
denale. 

Etiology. — Worms are developed from the ingestion of 
their eggs into the alimentary canal with food, drink, or air. 
People who have pet dogs and cats in the house are most 
exposed, as these animals are commonly affected and drop 
the eggs of the worm. 

General Symptoms. — Some cases present no symptoms. 
Others have disordered digestion and pain in the umbilical 
region. Itching at the anus and nose, hence scratching and 
picking. Thirst, ravenous appetite, emaciation, palpitation of 
the heart, sympathetic cough, disordered senses, convulsions, 
fever, and vertigo in some cases ; insomnia ; passage of the 
worms or part of them or their ova. Three prominent classes 
are met, and these only will be considered. 



236 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



TAENIA SOLIUM. 

Description. — The common tapeworm is developed in the 
small intestines from ova ingested with pork or raw beef. 
There is usually one, but there may be many. It measures 
from twenty to forty feet in length. The tapeworm is made up 
of joints that become detached and are passed with stools or 
drop away spontaneously. Average life of worm is ten years. 
The head is buried deeply in the mucous membrane and holds 
on by two or four hooks or suckers. Each joint is capable 
of reproduction, and contains the male and female organs. 
Patient has colicky pains, choreic movements, hysteria, in- 
somnia, intestinal catarrh, and passes segments of the worm 
— the only reliable point of diagnosis. 

Treatment. — Give light liquid diet for three or four days, 
and follow with a good cathartic of Epsom salts, one dram in 
a glass of water, to remove mucus from the imbedded head. 
Repeat this for several days ; follow with ethereal oil of male 
fern, 3 ss-j, and extract of tansy, 3 ij. Two or three hours 
after taking this dose give castor-oil, 1 iss, and let the bowels 
be opened over a bucket of hot water, so that the worm will 
not break when passed. Examine to see if the head has come 
away. An equally efficient and less dangerous remedy is 
pumpMn-seecl, 1 ii-iv. The seed must be administered with the 
greenish skin that covers it, for in it is the active principle. 
Pelletierine, or decoction of pomegranate, is recommended. 

ASCARIS LUMBRACOIDES. 

Description. — The round-worm measures from three to eight 
inches in length ; resembles an ordinary earth-worm in appear- 
ance, although anatomically different ; inhabits the small in- 



DISEASES OF THE INTESTINES. 237 

testines; lives about one year. The female is the larger. 
Ova are taken in with food and drink. Most common in fe- 
males, vegetarians, and debilitated persons. Catarrh of the 
bowels favors its development. Worms may crawl into the 
stomach, throat, Eustachian tube, mouth, nares, or gall-duct. 
Blueness of the lower eyelids ; picking at the nose ; uneasiness 
and intestinal catarrh ; gritting the teeth and starting up 
from sleep (night terrors) ; colicky pains or diarrhoea ; or there 
may be no symptoms at all. Passing of worms or their ova 
constitutes the main and only reliable point of diagnosis. 

Treatment. — Precede all treatment with light diet and 
cathartics. Cowage down, or the spears on the pod of Mucuna 
pruriens, is the best remedy. Prepare by dipping the pods in 
molasses j scrape with a knife, and give two teaspoonfuls of 
the scraped product every morning, for three mornings j fol- 
low with a brisk cathartic. These little spears will pierce the 
worms, kill them, and not produce an undue amount of irrita- 
tion to the bowels. Santonin, gr. i-ij, with calomel, gr. i-ij, 
at bedtime, will bring away some of the worms. Chenopo- 
dium ambrosioides — American wormseed — with calomel, acts 
nicely. Spigelia or turpentine with mucilage will often an- 
swer. Treat catarrhal conditions of the bowels, anaemia, and 
specific troubles; build up the patient, and as the child 
strengthens the worms abort. 



OXYURIS VERMICULARIS. 

Description. — Thread or seat worms measure from two to 
five lines in length ; female is the larger. They are pearly- 
white, slender, and very active ; inhabit the rectum and 
vagina. Intense itching at the anus, with burning sensation 
and symptoms of proctitis. Worms are found at the anus ; 



238 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

may enter vagina and canse vaginitis. Child is nervous, sub- 
ject to convulsions, and liable to practice masturbation. 

Treatment. — Regulate diet and hygiene. Give a purge of 
calomel with aloes and santonin. Injections of saturated lime- 
water to which tr. f erri chloridi has been added, 3 ii-Oss ; 
carbolic acid and warm water j turpentine or petroleum with 
hot water and soap • ice- water and quassia. It is well to pre- 
cede injections by a free purge with Rochelle salts. Glycerin 
with carbolic acid (one percent.) may answer. Wash anus 
and genitals with carbolic or bichloride solution, and use a 
dusting-powder to prevent external irritation. 



DISEASES OF THE PERITONEUM. 



PERITONITIS. 

Definition. — An inflammation of the peritoneum, acnte or 
chronic, local or general, with a fibroplastic exudation, accom- 
panied by severe pain, fever, tympanites, vomiting", and marked 
depression. 

Etiology. — Acute Peritonitis. — Direct injury; hernia; per- 
foration of the intestines from ulcers or abscesses ; extension 
from other organs j pyaemia ; septicaemia ; erysipelas ; puer- 
peral infection ; great heat or cold. May be idiopathic. 

Chronic Peritonitis comes from tuberculosis ; Bright's disease 
of the kidneys ; cancer ; cirrhotic diseases of the liver ; and 
from the acute. 

Symptoms. — Acute. — Idiopathic cases commence with a 
chill, intense fever, pain, and tenderness. Other cases come 
on slowly with sharp pain, gradual rise of temperature, and 
local tenderness. Abdomen becomes so tender that the slight- 
est touch causes great pain. Patient lies on his back, with 
thighs flexed on abdomen to relax the abdominal muscles. 
Cough suppressed on account of great pain ; deep breathing 
impossible ; abdomen swollen and tympanitic, causing com- 
pression of the lower lobes of lung, with dyspnoea and even 
cyanosis ; bowels constipated ; vomiting of food, serum, and 
bile ; temperature 105° to 106° F. ; mind very clear. When 
exudation appears, pain is not so severe. Hiccup may super- 
vene, with delirium, fall of temperature, and death. 

239 



240 A SYNOPSIS OP THE PRACTICE OF MEDICINE. 

Chronic peritonitis has some fever of hectic type ; local ten- 
derness, with a feeling of oppression and weight ; constipa- 
tion, alternating with diarrhoea 5 irregular appetite ; vomiting 
at times. May be constitutional symptoms of tuberculosis. 
Peritoneal cavity is filled with fluid, giving fluctuation and 
distention ; or there is little fluid, with a flat, resistent abdo- 
men and hard, irregular surfaces here and there. Rapid 
emaciation ; dullness on percussion, general or local. 

Pathology. — Acute Peritonitis. — Peritoneum is reddened 
from hyperemia and covered with a fibrinous exudation that 
causes adhesion of the parts. Exudation may fill the peri- 
toneal cavity and amount to several gallons ; if absorbed, 
adhesions remain. 

Chronic Peritonitis. — Peritoneum is thick and matted to- 
gether ; liver, spleen, and intestines are adherent ; effusion is 
serous ; may contain pus, and is either localized in cavities or 
general. In tubercular peritonitis, peritoneum is thickly 
studded with tubercles. 

Diagnosis. — Colic and hysterical pains are slightly relieved 
or not increased by deep pressure ; no rise in temperature. 
Intestinal obstruction is easily diagnosed after a few days. 
Toxic gastritis has the history ; constant vomiting and tender- 
ness, limited to stomach. Inflammatory troubles of the intes- 
tines commonly have pronounced diarrhoea. 

Prognosis. — Usually fatal, when due to perforation. Acute 
cases favorable ; chronic cases are usually hopeless, but some 
are recorded as cured. 

Treatment. — Acute. — Avoid active purgation in all cases. 
Idiopathic cases are relieved by constant applications of ice- 
water, applied to the abdomen every minute, with soft cloths, 
until temperature falls. This answers better than antipy- 
retics. Magnesium sulphate, 3 ss-j, with tr. belladonnae, every 
four hours, in plenty of water, to deplete the intestinal mucous 



DISEASES OP THE PERITONEUM. 241 

membrane and blood-vessels, without causing peristaltic ac- 
tion. Opium should be withheld until it is found absolutely 
necessary to relieve pain ■ then it must be pushed to the point 
of tolerance. Hot poultices, in localized peritonitis, as well as 
warm compresses and counter-irritation. Blood-letting is not 
required. Tympany is relieved by aspirator, rectal tube, or 
intestinal antiseptics. In perforation, insist on absolute quiet 
and rest ; surgical operation if patient's condition will permit. 
As most cases of perforation are fatal, all we can do is to give 
opium to relieve pain and resort to surgical means. Vomiting 
is relieved by ice internally. Give blandest diet. 

During convalescence, potassium iodide and mercury, with 
iron, cod-liver oil, and the phosphates ; connter-irritation over 
abdomen. Stimulate freely when necessary. If local effu- 
sion of serum impedes respiration, draw off a small portion 
of it at a time. 

Chronic peritonitis requires flying blisters over abdomen. 
Diuretics, diaphoretics, and evacuants often cause effusion to 
absorb. Laparotomy is practiced successfully for its relief, 
especially in the tubercular form. Build up patient with iron, 
quinine, and cod -liver oil. Best foods. 

Cancerous or malignant peritonitis is always fatal, and treat- 
ment is only palliative. 



ASCITES. 

Synonyms. — Abdominal dropsy ; peritoneal dropsy. 

Definition. — An effusion of fluid into the peritoneal cavity, 
dependent upon some diseased condition. 

Etiology. — Chronic peritonitis ; portal obstruction ; dis- 
eases of the heart, lungs, liver, or kidneys ; any obstruction to 
the circulation. 



242 A SYNOPSIS OP THE PRACTICE OP MEDICINE. 

Symptoms. — Local signs are enlargement of the abdomen ; 
dullness on percussion, that changes with the posture of 
patient ; distinct succussion wave, indicating presence of fluid. 
Intestines always float to the surface of the fluid. Percussion 
gives a tympanitic note at the umbilicus, with dullness in the 
flanks, when patient lies on his back. When standing, tym- 
pany is at the epigastrium and dullness below. Liver, spleen, 
and stomach may be displaced ; pressure on lower lobes of 
the lungs causes dyspnoea. Digestion impaired ; bowels con- 
stipated j symptoms of causative trouble. 

Pathology. — Peritoneum is thickened, opaque, and presents 
a macerated or water-logged appearance. Fluid is albumi- 
nous 5 rich in salts ; high specific gravity ; varies in color from 
a pale amber to a red ; may amount to several gallons in 
quantity. 

Diagnosis. — In ovarian cyst, dullness is in the median line 
and tympany in the flanks ; center of abdomen is prominent, 
in place of a uniform enlargement. Chronic peritonitis has 
pain and tenderness, with a tuberculous or cancerous history. 
Pregnancy and distended bladder present their peculiar charac- 
teristic symptoms, and should never be mistaken. 

Prognosis. — Depends on cause. Usually bad, as regards 
cure. Patients die of the primary disease. 

Treatment. — Strike directly at the cause and treat diseases 
of the heart, lungs, kidneys, liver, or other organs. Reduce 
effusion by hygienic, medicinal, and surgical means j dry diet, 
and limit amount of liquids ; guard against taking cold ; good, 
nourishing food. Medicines consist of diuretics, diaphoretics, 
purgatives, and alteratives. Elaterium, jalap, jaborandi, and 
Dover's powder all have their place in treatment, but de- 
press the patient. 

When these means fail, resort to surgical measures. Draw 
off part of the fluid at a time with an aspirator or trochar. 



DISEASES OF THE PERITONEUM. 243 

It is not well to remove all the fluid at one time, for it drains 
too much albumin from the blood by refilling again. Chronic 
peritonitis is sometimes cured by removing all fluid at one 
time. Dry diet, iron, quinine, cod-liver oil, and treatment of 
the causative disease constitute the points in treatment. 



DISEASES OF THE PANCREAS. 

PANCREATITIS. 

Description. — Inflammation of the pancreas is acute or 
chronic, and is never positively diagnosed in life. Prominent 
symptoms are pain and oppression in the epigastric region ; 
retching, and vomiting of bilious matter ; severe salivation ; 
colicky pains ; pulse full, tense, and irregular ; stools contain 
fat and a material that resembles saliva; jaundice may be 
present from occlusion of the bile-duct. Pain is not altered by 
food, but increased by erect posture ; sugar often present in 
the urine. Terminates in collapse in four or five days ; or, in 
the chronic form, with formation of abscesses or cysts that 
may ulcerate into the peritoneum. 

Treatment. — Little can be done except to palliate. Rest in 
bed ; light diet without any fat ; morphina for pain ; counter- 
irritation and hot fomentations. In the later stages, potas- 
sium iodide and mercury ; quinine, iron, and supporting treat- 
ment. Alkaline salts are recommended. Treat symptoms. 

CANCER OF THE PANCREAS. 

Description. — Cancer of the pancreas is primary or second- 
ary ; scirrhous or medullary. The head of the gland is the 
most frequent seat. Pain is the main symptom. Cachexia; 
emaciation ; loss of appetite ; vomiting ; jaundice, at times j 
tumor in the epigastrium, in some cases. Stools are fatty. 

Treatment is palliative; cases rarely last more than six 
months or a year. 

244 



DISEASES OF THE LIVER AND APPENDAGES. 



INTRODUCTION. 

The liver varies in weight under conditions of age, sex, 
functional activity, disease, and health. Its main function is 
the excretion and secretion of bile. Average weight in an 
adult is about one fortieth of the body weight ; in children 
from one twentieth to one thirteenth. It is about twelve 
inches long, six inches broad, and three inches thick at its 
greatest thickness. 

Percussion dullness, in health, limits it between the fifth in- 
terspace, the lower border of the ribs, and to the right of the 
median line. Deep inspiration causes the liver to descend 
nearly one inch. Position varies in males and females, owing 
to the pernicious habit of lacing and corsets in the latter. 

Palpation reveals whether it is smooth, roughened, or nodu- 
lated ; whether the border is sharp or rounded ; whether it is 
hard or soft, large or small. 

Pain is generally dull, and radiates to the thorax, scapula, 
shoulder, and umbilicus ; is constant, and increased by deep 
pressure. 

Digestive troubles accompany hepatic affections, and vary 
from slight indigestion to violent gastro-intestinal catarrh. 

Disturbed circulation is common, and gives rise to dropsy, 
hemorrhoids, jaundice, hemorrhage from the stomach or in- 
testines, inflammatory changes in peritoneum, enlargement of 
the spleen, and superficial abdominal veins. 

Jaundice of all grades — not always present in liver-diseases. 

245 



246 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

JAUNDICE. 

Synonym — Icterus. 

Definition. — Jaundice is a symptom of some hepatic dis- 
order, manifested by a peculiar yellowness of the skin, con- 
junctiva, and mucous membranes ; the presence of biliary 
matter in the urine and secretions ; itching of the skin ; and 
white, offensive, putty-like stools. 

Varieties. — Catarrhal jaundice ; icterus neonatorum ; hepa- 
togenous jaundice ; haematogenous jaundice. 

Etiology. — Obstruction, partial or complete, of the bile-duct 
or any of its radicles in the liver, by gall-stones, hydatids, 
distomata, stricture, cancer, or tumors ; portal obstruction ; 
cirrhosis 5 atrophy; poisons, such as phosphorus, arsenic, 
mercury, or antimony ; concussion of the brain and nervous 
causes ; hyperemia and the specific fevers. 

Symptoms. — Conjunctiva, skin, and mucous membranes 
are discolored, yellow, and vary in color from a pale^ellow 
to a dark-brown or greenish tint. Urine contains bile pig- 
ment, and gives the characteristic play of colors with nitric 
acid. Bile is detected in the saliva and other secretions. 
Fceces are putty-like or whitish, and are highly offensive; 
pulse slow ; general malaise ; debility and stupor ; temperature 
subnormal. Itching of the skin is a prominent symptom ; 
bitter taste in mouth ; loss of appetite. A sudden blackening 
of the stools means a free discharge of bile. In addition, 
there are the symptoms of the causative trouble. 

Pathology. — Hepatogenous jaundice is due to an obstruc- 
tion to the normal outflow of bile. Bile is taken up by the 
circulation, produces an excitement of the nervous centers 
first, and soon causes drowsiness, stupor, coma, and death. 
Pathology of the causative affection. 

Hematogenous jaundice is not positively explained, but is 



DISEASES OF THE LIVER AND APPENDAGES. 247 

supposed to be due to a failure of the liver to perform its 
proper function in the formation and elimination of the bile. 
Others claim that the blood is the tissue at fault. 

Icterus neonatorum, or jaundice in the new-born, cannot be 
explained with our present knowledge on the subject. 

Diagnosis. — Easily made from the symptoms. 

Prognosis and Treatment depend on the cause. (See 
Catarrh of Bile-ducts, and other diseases of liver.) 



HEPATIC HYPEREMIA. 

Synonyms. — Hepatic congestion; biliousness ; congestion 
of the liver. 

Definition. — An acute or chronic congestion of the liver, 
symptomatic of a constitutional or local disorder, accompanied 
by impaired digestion and biliary function. It is either active, 
when due to arterial trouble, or passive, when due to venous. 

Etiology. — Active hypercemia is due to over-eating ; alcohol ; 
spices and condiments ; fevers ; malaria ; arrested menstrua- 
tion ; heat and cold. 

Passive hyperemia arises from obstructive diseases of the 
heart, lungs, kidneys, or pleura ; compression of the vena cava 
by tumors. 

Symptoms. — Active Hypercemia. — Pain and feeling of 
weight in hepatic region; liver dullness increased; tenderness 
to pressure ; sense of a band around the abdomen j uneasi- 
ness; constipation; vomiting at times; marked indigestion; 
headache; slight fever ; anorexia ; and bad taste in the mouth. 
Conjunctiva has a yellow tinge and indications of slight 
jaundice. 

Passive hypercemia is slow in onset ; liver dullness increased ; 
marked symptoms of indigestion ; slight jaundice ; and symp- 



248 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

toms of causative trouble. Hemorrhoids and ascites are 
common. 

Pathology. — Hypercemia is but the first stage of cirrhosis. 
A section of the liver appears like a section of nutmeg, hence 
the term u nutmeg liver." Liver increases in size, and finally 
contracts or atrophies, if the process is chronic. Headache 
and gastric disorders are due to improper elimination of bile. 

Prognosis. — Acute is good ; passive depends on cause. 

Treatment. — Acute Hyperemia. — Forbid all alcoholic and 
malt liquors, spices, condiments, and rich foods. When due 
to over-eating, a good dose of calomel and soda is indicated. 
Calomel does not increase the secretion and excretion of bile, 
but favors its formation and elimination. Malarial causes 
require quinine. Treat all fevers and digestive disorders. 
Leeches, counter-irritation, and cold compresses to the liver. 

Chronic hyperemia demands causal treatment. Sodii phos- 
phas, 3 i-ij, ter die, nitromuriatic acid, taraxacum, carbonated 
and alkaline waters are good. Stimulate when necessary; 
improve hygiene and diet. In all cases keep the skin active 
and attend to other functions. 



ACUTE SUPPURATIVE HEPATITIS. 

Synonym. — Abscess of the liver. 

Definition. — An acute inflammation of the cellular struct- 
ure of the liver, terminating in the formation of single or 
multiple abscesses. 

Etiology. — Most common in males, in malarial districts 
and hot climates ; seldom seen in the temperate zones. Caused 
by wounds ; contusions ; gall-stones ; septic thrombi ; dysen- 
tery ; operations for hemorrhoids; pyaemia; acute or chronic 
hepatitis. 



DISEASES OF THE LIVER AND APPENDAGES. 249 

Symptoms. — Some cases are so obscure as to attract no 
notice until the abscess or tumor is discovered. Symptoms 
may be those of debility ; irritable nervous system ; and slight 
febrile attacks; chills; and pycemic fever; slight jaundice — not 
always present; loss of appetite; slight cough; vomiting; 
weight and oppression in hepatic region. Locally, in marked 
cases, hepatic region is prominent and fluctuation can be 
detected; local or general tenderness; throbbing, dull pain 
reflected to the shoulder and back. Abscess may break through 
the skin into peritoneum, intestines, stomach, pleura, or lungs. 

Pathology. — An inflammatory action sets up in the liver- 
cells at one or more points, from one of the causes mentioned ; 
the inflamed mass becomes infected with pyogenic germs ; a 
disintegration or breaking down of the tissues, with diape- 
desis of white blood-cells and formation of an abscess. One 
or more abscesses may form and break into the surrounding 
structures or become encapsulated. They vary in size from 
a pea to a hen's egg or larger. 

Diagnosis. — Presence of pus, demonstrated by an aspirat- 
ing needle ; sudden vomiting or coughing up of pus, or pass- 
ing it by the bowels, associated with local and general 
symptoms, constitute the positive diagnostic points. 

Prognosis. — Usually bad ; some cases recover. 

Treatment. — Symptomatic. Large doses of quinine for 
malaria and pyasmic fever ; most stimulating diet, with wine 
and supporting treatment ; cold compresses or hot turpentine 
stoops to the liver; morphina to relieve pain. As soon as 
abscess is suspected, use aspirator and remove pus ; tr. iodini 
or other antiseptics may be injected into the cavity. Lapa- 
rotomy is justifiable when abscess is demonstrable. Cleanse 
with peroxide of hydrogen when opened with the knife. I 
recently met with a case of hepatic abscess in my own prac- 
tice, and removed one quart of pus with an aspirating needle. 



250 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Recovery complete, and abscess has not refilled. The patient 
is strong, hearty, and at hard work. (See Med. Bulletin.) 

INTERSTITIAL HEPATITIS. 

Synonyms. — Cirrhosis of the liver j sclerosis of liver ; hob- 
nailed liver; gin-drinkers' liver. 

Definition. — An inflammation of the interstitial connective 
tissue of the liver, giving rise to cicatricial bands which con- 
tract, canse an atrophy of the liver-cells and a local or general 
diminution in the size of the organ, interfering with its nor- 
mal physiological action. 

Etiology. — Principal cause is habitual use of alcohol, in 
frequent, small amounts ; condiments j idiopathic ; passive 
congestion. Fagge says, " Syphilis does not cause cirrhosis." 

Symptoms. — First stage of cirrhosis presents symptoms of 
a low grade of hypermmia ; an uneasy feeling, with now and 
then slight pain, in the region of the liver, most marked after 
eating or drinking ; slight gastro-intestinal disturbance. Grad- 
ually the symptoms increase until the second stage or stage of 
contraction occurs. Abdominal veins enlarged; marked abdom- 
inal ascites; persistent gastrointestinal catarrh; attacks of 
jaundice, becoming chronic in character; hemorrhage from 
the stomach and bowels; pain in the. liver ; spleen enlarged, 
congested, and may be involved by the same process ; hemor- 
rhoids. Urine rich in urates and bile pigments ; shin presents 
a dirty-yellow appearance ; fceces clay-colored. 

Palpation and Percussion. — In first stage liver is enlarged 
and smooth. Second stage presents a small area of dullness ; 
liver feels hard and nodulated. 

Pathology. — Constant irritation to the interstitial connect- 
ive tissue (Grlisson's capsule) ; increased blood-supply ; diape- 
desis of leucocytes; and formation of new tissue, causing a 



DISEASES OF THE LIVER AND APPENDAGES. 251 

temporary enlargement of the organ. This newly formed cica- 
tricial tissue contracts and causes atrophy of the liver-cells, 
with diminution of the size, and nodulated appearance. A 
hypertrophic form, in which the organ remains enlarged, gives 
rise to more profuse jaundice, with tendency to fever and peri- 
tonitis. Gastro-iiitestinal symptoms, enlarged spleen, and 
dropsy come from obstruction to portal circulation. Peri- 
toneum covering liver is thickened and adherent. 

Diagnosis. — Chronic atrophy is uniform, and liver presents 
no nodulated feel. Cancer is more rapid, marked cachexia, 
age, and nodules, independent of alcoholism. 

Prognosis. — First stage is good. In second stage we can 
only palliate. Destroyed liver-tissue cannot he restored. 

Treatment. — All alcoholics and condiments must be stopped 
at once ; gastro-intestinal catarrh needs attention ; treat first 
stage as in hyperemia. 

Second Stage. — Treatment is palliative. Put on dry diet to 
reduce ascites. Chloride of gold and mercury will not restore 
destroyed liver-cells, as claimed. Oxide of zinc, nitrate of 
silver, or hydrastis for gastro-intestinal catarrh. Iron, bit- 
ters, cod-liver oil, and mineral tonics increase catarrhal symp- 
toms. Alkaline carbonates are too depressing. Predigested 
diet; sour foods, such as raw oysters with vinegar, soused 
pigs' feet and tripe ; peptonized milk and meat. Avoid fats 
and sugars. If ascites becomes severe, resort to tapping. 
Hemorrhage may demand astringents. 

SYPHILIS OF THE LIVER, 

Description. — Syphilis may be congenital or acquired, and 
causes a perihepatitis or a partial interstitial hepatitis. Gumma 
form in the liver, causing destruction and atrophy of its 
cells, and are frequently scattered through the whole organ 



252 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

as small hemp-seeds, and cause a cheesy degeneration. Most 
common in children and rarely suspected until after death. 
Cirrhosis complicates ; ascites and jaundice may or may not 
be present, according to size and position of gumma. Albu- 
minuria is frequent ; may have fever of hectic type. 

Treatment. — First stage demands iodides and mercury to 
check the disease. Treat symptoms as they arise. (See 
Syphilis.) 

AMYLOID LIVER. 

Synonyms. — Lardaceous, albuminoid, or waxy liver ; scrof- 
ulous liver. 

Definition. — A waxy degeneration of the liver-cells, in 
which the normal cellular elements are replaced by an amy- 
loid or starch-like substance ; so called because it gives the 
same characteristic reaction with iodine as starch. 

Etiology. — Most common in tuberculous subjects and pa- 
tients suffering with prolonged suppuration of bone, syphilis, 
and chronic malaria. 

Symptoms. — Indigestion, nausea, vomiting, and diarrhoea. 
Jaundice rare ; feeling of fullness over liver ; pain slight or 
entirely absent ; liver dullness increased — may be twice the 
normal size ; palpation gives a hard feeling, with smooth 
surface and rounded edge ; spleen enlarged ; anaemia ; urine is 
increased, contains albumin, and, at times, may give starch 
reaction. Ascites is rare. 

Pathology. — Liver enlarged, pale, smooth, shiny, and cuts 
like wax. Waxy material is found in the liver-cells and 
capillaries. Iodine applied to a section gives a brown or blue 
reaction. Aniline violet stains the amylaceous matter pink, 
and liver structure violet or blue. Other organs undergo the 
same change. 



DISEASES OF THE LIVER AND APPENDAGES. 253 

Prognosis. — Unfavorable. 

Treatment. — Remove the cause ; stop suppuration in bones 
and joints ; treat syphilis and tuberculosis. Potassium iodide, 
hydriodic acid, quinine, and iodide of iron. Treat symptoms. 
Stimulate and give good diet. 

FATTY LIVER. 

Description. — Fatty degeneration of the liver is due to cor- 
pulence and wasting diseases, such as cancer or consumption. 
Liver is large, smooth, and infiltrated with fat ; liver-cells con- 
tain f at-globules ; fat is deposited in the parenchyma ; liver is 
doughy, and pits on pressure ; edge is rounded ; cuts very 
easily. Subjective symptoms are not marked. Objective 
symptoms show an increased area of dullness over liver ; no 
pain on pressure ; no jaundice, except in bad cases ; obstinate 
diarrhoea. 

Treatment. — Remove cause ; treat corpulency, phthisis, or 
debilitating diseases. Never give cod-liver oil or fat, as it in- 
creases the difficulty. Treat diarrhoea with astringents ; meet 
all complications as demanded. 

HEPATIC CANCER. 

Synonyms. — Cancer of the liver ; hepatic carcinoma. 

Definition. — A malignant growth in the liver, primary or 
secondary : occurring after the fortieth }^ear ; accompanied by 
pain, cachexia, and hepatic disorders. 

Etiology. — Cancer of the liver is hereditary, or develops 
primarily under some irritating influence ; extends from other 
organs, and is secondary. Most common in women between 
the fortieth and sixtieth years. 

Symptoms. — During the early stages symptoms are ob- 
scure. Later, there is a fullness and weight in the right hypo- 



254 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

chondrium ; severe shooting pain, reflected to right shoulder 
and umbilicus ; great sensitiveness to pressure ; liver enlarged, 
and one or more nodular tumors may be felt. Ascites, gastro- 
intestinal catarrh, hemorrhage, and jaundice accompany when 
the portal circulation and gall-ducts are obstructed by the 
tumor. Feet swollen ; thrombosis of femoral veins not un- 
common ; ascites may conceal physical signs, and requires tap- 
ping before satisfactory examination can be made. 

In all forms of cancer the red corpuscles of the blood num- 
ber between one and two million to the cubic millimeter, and 
if taken with other symptoms are almost diagnostic. 

Pathology. — Medullary cancer is most common, and varies 
from a large, soft, friable mass to a hard, lobulated, scirrhous 
variety. May be soft, disintegrating, and black ; marked hy- 
peremia ; atrophy and degeneration of the liver-cells ; local 
and adhesive peritonitis, if the cancer is near the surface of 
the organ ; whole gland infiltrated at times, or, rarely, a small, 
isolated epithelioma is found. 

Diagnosis. — Age 5 cachexia ; marked ascites ; anaemia ; 
blood-count; pain and local tenderness; nodulated tumor; 
rapid emaciation and decline of patient. 

Prognosis. — Always bad ; patients die within the first year. 

Treatment. — Relieve local pain by leeches, counter-irrita- 
tion, or morphina ; remove small amounts of fluid from abdo- 
men at a time. Clinical experience shows that arsenic, conium, 
mercury, and other drugs only palliate, and death will result 
sooner or later. 

HYDATIDS OF THE LIVER. 

Description. — Hydatids, single or multiple, are due to the 
Tarnia echinococciis, a peculiar form of tapeworm, and consist 
of cystic tumors that contain a colorless, non-albuminous fluid 



DISEASES OF THE LIVER AND APPENDAGES. 255 

and the eggs of the worm. Most common in Iceland ; is dne 
to the ova of the worm, which are derived from dogs, sheep, 
and pigs, and are carried through the air, water, and food into 
the system, and develop in the spleen, liver, or kidneys. 
Cysts project from surface of liver as fluctuating tumors; 
they sometimes dry up, or continue to enlarge and ultimately 
rupture. Little or no jaundice ; no fever or tenderness ; ob- 
struction of portal circulation or bile-ducts, by pressure, 
causes jaundice, gastro-intestinal symptoms, ascites, and en- 
larged spleen. 

Diagnosis. — Determined by aspirator, non-albuminous fluid 
and presence of ova, demonstrated by microscope. 

Prognosis is good ; if there are multilocular cysts it is bad. 
Hydatids last about four years and grow very slowly. 

Treatment. — Draw off fluid with aspirator, and inject a so- 
lution of fel bovinum or tr. iodini. Electrolysis, with needles 
thrust into the cyst, sometimes cures. If suppuration is sus- 
pected, open freely and treat as suppurative hepatitis. At- 
tend to diet and hygiene. Multilocular cysts resist all treat- 
ment and are fatal. 

ACUTE YELLOW ATROPHY. 

Synonyms. — Malignant jaundice ; hemorrhagic jaundice ; 
acute parenchymatous degeneration of the liver. 

Definition. — An acute, degenerative inflammation of the 
cellular elements of the liver, which results in marked jaun- 
dice, great depression, nervous symptoms, atrophy of the 
liver, and terminates fatally. 

Etiology. — Most common in young pregnant women; 
syphilis ; venereal infection ; poisoning by phosphorus, anti- 
mony, or arsenic. 

Symptoms. — Prodromal symptoms are gastro-intestinal ca- 



256 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

tarrh, tenderness of abdomen, rapid pulse, headache, and slight 
jaundice. Onset is heralded by vomiting of mucus and a dirty- 
brown or black material not unlike that of yellow fever. Pa- 
tient is desperate, delirious, or comatose ; convulsions or tris- 
mus ; dilated pupils ; temperature 104° F. ; pulse very rapid ; 
tongue and teeth coated; spleen enlarged; and jaundice 
marked. Hemorrhage from the nose, bronchi, or stomach, 
which ultimately results in death. 

Pathology. — Liver nearly one half its original size ; capsule 
puckered and yellow; a dirty-gray deposit between lobules, 
and lobules contain leucin ; fatty degeneration. Gall bladder 
and ducts empty ; blood thick and dark ; urine contains bile 
and albumin ; kidneys pigmented, and brain softened. Nerv- 
ous symptoms are due to toxaemia. Pathology is not posi- 
tively explained. 

Prognosis. — Duration is from twelve hours to one week, 
and recovery is rare. 

Treatment. — Since pathology is unknown, treatment is en- 
tirely symptomatic. A large, free purgative at onset, regard- 
less of pregnant condition. Mineral acids, alcohol, nux vom- 
ica, small doses of phosphorus, and counter-irritation are 
palliative measures. Ice, hydrocyanic acid, bismuth, and ar- 
senite of copper are given for vomiting. 

PYLEPHLEBITIS. 

Description. — An inflammation of the branches of the por- 
tal vein and the tissues in which they are imbedded. There 
are two distinct classes : the suppurative and adhesive. 

Suppurative pylephlebitis is due to the extension of some sup- 
purative inflammation to the walls of the portal vein and its 
branches ; or from septic thrombi, due to abscess of the stom- 
ach, spleen, or other organs. Inflammation begins in vessel- 



DISEASES OF THE LIVER AND APPENDAGES. 25? 

wall ; a thrombus is formed ; it suppurates, aud causes ulcera- 
tion of the vein, dissemination of pus into general circula- 
tion, and pyaemia. There is pain in epigastrium ; engorged 
spleen and ascites. Jaundice is absent; chills; fever; and 
symptoms of pyaemia. Frequent vomiting; diarrhoea, alter- 
nating with constipation. This is a rare condition and is 
always fatal. Treatment is palliative. 

Chronic adhesive pylephlebitis, or non-suppurating thrombus 
of portal vein, is caused by pressure of tumors, cirrhosis of 
liver, syphilis, or thickening of pylorus. Symptoms are those 
of congestion ; engorged spleen ; catarrh or hemorrhage of 
stomach and intestines ; obstinate ascites ; and marked collat- 
eral circulation through omentum ; liver atrophies, and is not 
tender. Treatment is the same as that of advanced cirrhosis 
of liver. 

CATARRH OF THE BILE-DUCTS. 

Synonym — Catarrhal jaundice. 

Definition. — A catarrhal inflammation of the mucous mem- 
brane of the bile-ducts, accompanied by varying degrees of 
jaundice and intestinal indigestion. 

Etiology. — Hyperaemia of liver; hepatic cancer; obstruct- 
ive heart-diseases ; extension from duodenal catarrh ; passage 
of gall-stones ; heat or cold ; malaria ; improper drink or diet ; 
most common in plethoric and inactive women. 

Symptoms. — Uneasiness and tenderness in region of liver ; 
gastro-intestinal disturbances; patty-liJce, offensive stools; 
tongue coated; little or no fever; heart slow and weak; 
symptoms of jaundice ; itching of skin ; urine loaded with bile 
and salts ; liver enlarged. Trouble leaves in a few weeks, but 
may become chronic and last for months, resulting in per- 
manent narrowing of the duct and consequent disorders. 



258 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Treatment. — Rest in bed. When due to duodenitis, treat as 
indicated in that disease. Hot drinks, with sodium bicar- 
bonate, to remove mucus from stomach and duodenum ; dia- 
phoretics, diuretics, and Carlsbad mineral waters. Nitro- 
muriatic acid before meals; sodium sulphate is the best 
laxative ; sodium phosphate in the chronic form. Regulate 
diet to skim-milk and lean beef; avoid starches, fats, and 
sugars. When local tenderness is marked, counter-irritation, 
leeches, hot poultices, or fomentations. Nothing will relieve 
pmiritis in this condition better than large doses of pilocar- 
pus to produce diaphoresis. 

HEPATIC CALCULI. 

Synonyms. — Gall-stones ; biliary calculi ; liver-stones. 

Description. — Gall-stones are hard masses composed of 
bile-salts, mucus, and inspissated bile. They vary in size 
from a hemp-seed to a hen's egg, and usually have a nucleus 
of hardened mucus. They are found in the gall-bladder, 
cystic duct, hepatic duct, or common bile-duct. There may 
be one or several hundred impacted in the gall-bladder. 

Symptoms. — As long as the stone remains in the gall-blad- 
der, no symptoms may be manifested ; many impacted stones 
are recognized by a hard tumor on palpation. When a gall- 
stone enters the duct, there is an attack of hepatic colic. With- 
out any previous symptoms, patient is seized with violent pierc- 
ing and griping pain in right hypochondrium, reflected to 
right shoulder and umbilicus; skin cold and clammy; liver 
enlarged and bulging ; pulse slow ; no fever ; convulsions and 
syncope from intense pain ; persistent and obstinate vomiting. 
After one hour or more the paroxysm ceases suddenly with 
complete relief, indicating the passage of the stone into the 
duodenum. 



DISEASES OP THE LIVER AND APPENDAGES. 



259 



Jaundice comes on after the attack, from inflammation of 
the mucous lining of duct j liver is tender for several days. 
Gall-stone is passed with stool, is vomited, or may have en- 
tered the gall-bladder again. Attacks may occur at intervals 
of a few days or weeks, if other stones remain. 

Sometimes gall-stones become impacted and cause ulcera- 
tion and peritonitis. Obstruction of the common duct by a 
gall-stone results in fatal jaundice or ulceration. 



Diagnosis. 



Hepatic Colic. 



Pain always on the right side. 
Pain reflected to right shoulder and 
umbilicus. 

Urine shows no pathological condi- 
tion. 

Stone is found in stools or vomit. 
Liver very tender ; jaundice after 
the attack. 



Renal Colic. 



Pain may be on right or left side. 

Pain reflected along ureter to testi- 
cle and head of penis, with re- 
traction of same. 

Urine bloody and contains evidence 

of the trouble. 
Stone is often found in urine passed. 

Tenderness in loins along ureter, 
with no jaundice after attack. 



Treatment. — Paroxysm. — Hypodermic of morphinse sul- 
phas, gr. i to i, with atropine sulphas, gr. y^, relieves pain, 
stops spasm of muscular coat of gall-duct, and favors passage 
of the stone. Anaesthetics ; morphina may be given internally 
in hot water j chlorodyne or chloroform, gtt. xx-xxx, every 
ten minutes j mustard poultices j hot fomentations. Yery hot 
alkaline drinks often relieve vomiting and assist in relaxing 
spasm. Stimulate if necessary. Resulting inflammation is 
treated with counter-irritation and alkalies. 

Preventive Treatment — Exclude fat, sugars, lime salts, and 
malted liquors from diet ; give only lean meat and vegetables. 

Internally. — Sodium phosphate, 3 j, with arsenious acid, gr. 
a 3 ^ three times daily, for months. Sodium succinate, gr. iij-v, 
three times a day, long continued, often produces a cure or 
cessation of attacks. It is doubtful if anything except bile 



260 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

will dissolve gall-stones in the gall-bladder. Alkalies, ether, 
fel bovinum, and turpentine are recommended for their so- 
called solvent action, but by the time they are taken into the 
blood and reach the liver and bile, they are so weak as not to 
accomplish this result. They may increase the flow and reac- 
tion of bile, causing it to act as the solvent. Moderate exer- 
cise, and all the emunctories should be kept active. Several 
ounces of olive-oil, given at one dose, may assist in the expul- 
sion of gall-stones, and has been recently recommended. 



DISEASES OF THE SPLEEN. 



SPLENIC HYPEREMIA. 

Synonyms. — Congestion of the spleen ; splenic fluxion. 

Description. — The spleen, normally, weighs about eight 
ounces, and its general structure favors active congestion. 
Acute congestion or fluxion is caused by malaria, typhoid fever, 
septicaemia, portal obstruction, relaxed splenic tissue, blows, 
injuries, exercise, and physiological enlargement after meals. 

Spleen becomes four times its normal size in some cases ; 
little or no pain ; local tenderness in left hypochondrium. 
Death may ensue from rupture. Area of percussion dullness 
is increased. 

Treatment. — Causal; quinine in large doses; cold douches 
directly over the spleen ; faradization or galvanism ; ergot hypo- 
dermically or by stomach ; removal from malarial districts. 

SPLENITIS. 

Description. — Inflammation of the splenic structure comes 
from excessive hyperemia, malaria, fevers, and embolic in- 
farctions. Primary inflammation is rare. Spleen is tender, 
swollen, and painful ; may become friable, cheesy, or result in 
abscess; localized peritonitis; sympathetic vomiting; chills 
and fever. 

Treatment. — Palliative. — Leeches, counter-irritation, and 
hot fomentations; ice and carbonated alkaline waters for 

261 



262 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

vomiting j morphina for pain. Evacnate abscess at once by 
aspirator or incision j quinine in full doses ; treat cause. 

SPLENIC HYPERTROPHY. 

Description. — Due to malaria, leucaemia, cirrhosis, or chronic 
splenitis. Spleen is broad, hard, and has rounded edges ; has 
a deep-brown color, or, if malarious, gray ; capsule thickened ; 
trabecula rigid ; pulp reduced to a cheesy mass ; anaemia ; short- 
ness of breath ; nasal hemorrhage ; hydraemia and dropsy. 

Treatment. — Quinine, in malaria ; change of residence to 
non-malarious district ; cold douches and electricity to spleen ; 
iron and arsenic for anaemia. Hypertrophy from pylephlebitis 
resists all treatment. To reduce ague-cake (a spleen enlarged 
from malaria), stand patient before a hot, open fire until the 
skin over spleen is red and glowing ; apply a piece of ung. 
hydrargyri oxidi rubri, as large as a walnut, and rub in well 
for several minutes ; allow it to bake in before the fire ; this 
process to be repeated daily. Ergot, hypodermically, may do 
good. 

AMYLOID SPLEEN. 

Description. — Amyloid degeneration of the spleen is asso- 
ciated with the same disease in the liver and kidney, and pre- 
sents similar symptoms. Spleen is heavy, hard, pale, smooth, 
and gives starch reaction with iodine. Anaemia, cachexia, 
dropsy, and marked increase of splenic dullness. 

Treatment is of little avail, and is entirely symptomatic. 



THE URINE. 

QUALITATIVE URINARY ANALYSIS. 

Normal urine varies under different circumstances of diet, 
heat, cold, and amount of liquid taken. More urine is passed 
when the pores of the skin are inactive. The average quantity 
passed in twenty-four hours is about forty to fifty fluid ounces 
(1200 to 1500 c.c). Color, pale amber, or shades of yellow due 
to presence of urobilin and indican. Reaction, slightly acid. 
Specific gravity varies from 1.015 to 1.020, and is determined by 
the urinometer. 

Normal constituents of urine are : urea, about five hundred 
grains (thirty grams) daily; uric acid, fifteen grains (one 
gram) ; phosphoric acid, thirty to sixty grains (two to five 
grams) ; chlorides, two hundred and forty-eight grains (six- 
teen grams) ; hippuric acid ; creatinine ; sulphuric acid ; salts 
of sodium, ammonium, potassium, calcium, and magnesium. 

Abnormal urine contains bile pigments or salts ; albumin ; 
glucose ; pus ; blood ; oxalic acid, or oxalates ; tyrosin ; leucin ; 
epithelial cells and tube-casts. 

CHEMICAL TESTS. 

ALBUMIN. 

Seat Test — Filter and acidify urine with acetic acid j fill 
test-tube nearly full of urine, and boil upper layers over spirit- 
lamp. If albumin is present, a coagulated mass is formed in 
the part boiled, and contrasted with clear urine below. Ad- 
dition of nitric acid will not dissolve coagula of albumin^ 

263 



264 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Nitric-acid Test. — (Heller's test.) Place several drops of 
pure nitric acid in bottom of test-tube, and allow urine to flow 
down sides of tube to form a distinct layer on the acid. If 
albumin is present, a white, coagulated ring appears at the 
zone of junction. 

Picric-acid Test. — A concentrated, acidulated solution of 
pure picric acid, added to urine, will coagulate albumin, and 
cause a precipitate if allowed to stand. 

SUGAR. 

IAquor-potassce Test. — (Moore's test.) To one part of urine, 
add one half as much liquor potassae ; mix thoroughly and 
boil upper layers ; contrast boiled part with the cold part be- 
low, and if sugar is present, the upper part is a canary-yellow 
or red. Nitric acid decolorizes it. 

Bismuth Test. — Treat two volumes of urine with one of 
liquor potassae ; add a small quantity of subnitrate of bismuth, 
and boil. Sugar reduces bismuth to the black suboxide. 

Fermentation Test. — Yeast added to saccharine urine at a 
warm temperature causes fermentation and generation of 
carbon dioxide. 

Fehliny's Test. — This consists of two separate preparations 
prepared and used as follows : 

No. l. 

Cupri sulphatis (pure crystals) 34.64 gin. 

Aquae destillatae ". q. s. ad. 500.00 c.c. 

No. 2. 

Potassii et sodii tartratis (pure cryst.) . . 173 gm. 
Sodii hydratis (solution 1.34 spec, grav.) 100 c.c. 
Aquae destillatae q. s. ad. 500 c.c. 



THE URINE. 265 

Mix equal volumes of these two solutions ; add a few drops 
of urine, after thoroughly boiling, and boil again. If sugar 
is present, red oxide of copper is precipitated. This is one of 
the most reliable tests. 

PHOSPHATES. 

Alkalinize urine with liquor potassee or aqua ammonise, and 
boil. Phosphates are precipitated as a light-colored flocculent 
precipitate ; acetic or nitric acid dissolves them. Magnesia 
mixture precipitates alkaline phosphates. 

URIC ACID. 

Add strong nitric or hydrochloric acid to urine. Uric acid 
precipitates as small reddish-brown crystals. 

BILE AND SALTS. 

One drop of fuming nitric acid placed on a porcelain plate 
and allowed to blend with a drop of urine causes a play of 
colors from green, blue, violet, red, yellow, to brown, when 
bile pigment is present. 

CHLORIDES. 

Nitrate of silver precipitates as a white chloride when added 
to urine containing chlorides. Mucus is precipitated by acetic 
acid, in the shape of delicate fibrillated bands, as mucin. 

MICROSCOPICAL EXAMINATION. 

By means of the microscope, blood, pus, epithelium, casts, 
crystals, and bacteria are detected. 



DISEASES OF THE KIDNEYS. 



URAEMIA. 

Description. — A symptom of kidney-disease due to suppres- 
sion of the normal excretion of toxic substances (urea) from 
the blood through the urine. Occurs in course of Blight's 
disease ; albuminuria of pregnancy (puerperal convulsions) ; 
obstruction of both ureters ; retention or suppression of urine ; 
and some fevers. 

Acute urcemia begins suddenly with convulsions (eclampsia) 
similar to epilepsy; wild, staring gaze; tonic muscular con- 
traction, followed by twitching clonic spasms ; pupils dilated ; 
pulse quick ; temperature high ; and coma. Recovery is the 
rule, if property treated. 

Chronic Urcemia. — Drowsiness; headache; nausea and vom- 
iting ; dilated pupils ; muscular twitching, without loss of con- 
sciousness ; chilliness ; fever ; dyspnoea at night. This condi- 
tion may go on a long time and suddenly develop an acute 
attack. Urine scanty; urates diminished; albumin present. 

Prognosis depends on the cause; always grave. Puer- 
peral eclampsia is often cured. 

Treatment. — Symptomatic, and depends on cause. Vene- 
section is valuable in plethoric persons ; free purgation ; dia- 
phoresis. In convulsions, administer anaesthetics, chloral, 
bromides, or morphina — the first two being the most reli- 
able. Keep patient absolutely quiet, and avoid excitement or 
irritants. 

266 



DISEASES OF THE KIDNEYS. 267 



RENAL HYPEREMIA. 

Synonym. — Congestion of the kidney. 

Definition. — An active or passive engorgement or conges- 
tion of the vessels of the kidney. 

Etiology. — Active Congestion. — Direct injury ; cold; fevers; 
medicines, such as turpentine and cantharides ; inflammation. 

Passive Congestion. — Obstructive diseases of heart, lungs, 
liver, or portal system; pressure of tumors on the venous 
trunks. 

Symptoms. — Active. — Xo pain or local tenderness ; little or 
no fever ; general malaise, headache, and sometimes vomiting ; 
irritability of bladder ; frequent micturition. Urine increased ; 
pale in color; low specific gravity. If renal veins are ob- 
structed, urine is scant} 7 , high-colored, contains blood, casts, 
and albumin. 

Passive. — Symptoms of cause ; urine scanty, high-colored, 
and loaded with urates. Pain in testicle and heavy feeling 
in loins ; no fever. 

Pathology. — Kidney is large, red, and engorged with blood ; 
Malpighian bodies red and inflamed ; epithelial lining of tu- 
bules in catarrhal state. Chronic congestion is the first stage 
of cirrhosis. 

Prognosis. — Active cases recover promptly, if properly 
treated. Passive cases are liable to cause Bright's disease, and 
depend on cause. 

Treatment. — Active Congestion. — Rest in bed; discontinu- 
ance of irritants ; mildest diet ; free use of alkaline waters to 
dilute and alkalinize urine ; no stimulating diuretics ; infusion 
of digitalis is best heart-tonic and diuretic; small doses of 
Epsom salts are recommended. Leeches, hot poultices, dry 
or wet cups over loins ; venesection in very acute cases ; free 



268 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

diaphoresis depletes blood and relieves tension on kidneys. 
Irritability of bladder is relieved by morphina, liquor arnmonii 
acetatis, and nnx vomica. 
Passive congestion is treated according to cause. 

ACUTE TUBAL NEPHRITIS. 

Synonyms. — Acute Bright's disease; acute desquamative 
or croupous nephritis ; acute parenchymatous nephritis. 

Definition. — An acute inflammation of the mucous lining 
of the uriniferous tubules, recognized by fever, pain over the 
kidneys, and scanty, high-colored urine, containing blood, 
albumin, epithelial cells, and tube-casts. 

Etiology. — Scarlet fever ; high fevers ; cold ; injury ; con- 
gestion, drugs. Most common in the young. 

Symptoms. — Onset sudden; chill, fever, and vomiting; 
constant desire to urinate; sharp pain over both kidneys. 
Uraemia may supervene. Urine small in amount (f 1 i-v 
in twenty-four hours) ; high-colored ; high specific gravity ; 
albumin (one half to one third bulk) ; blood ; salts ; epithelial 
cells and tube-casts. Local or general dropsy soon appears, 
beginning by pufliness under the eyes. Patients are very 
susceptible to such complications as pneumonia, pleurisy, 
peritonitis, or pericarditis. 

Pathology. — Kidney enlarged ; capsule thick, opaque, and 
not adherent ; color deep red ; uriniferous tubules swollen and 
filled with epithelial cells, blood, and mucus. Dropsy is due 
to obstructed circulation and suppression of urine. 

Prognosis. — Lasts one to five weeks, and usually termi- 
nates in recovery. May have any of the complications. 

Treatment. — Rest in bed ; diet of skimmed milk and broths ; 
pure alkaline waters, freely used ; counter-irritation, cups, or 
leeches over kidneys; regulate bowels daily with saline 



DISEASES OP THE KIDNEYS. 269 

cathartics. Tr. aconiti, gtt. j, every half -hour, often relieves 
acute cases. 

Dropsy lessened by elaterium, oleum tiglii, jalap, or mag- 
nesii sulphas internally; free diaphoresis by hot baths or 
pilocarpus jaborandi. Potassii acetas, gr. xv, with infusion 
digitalis, f 3 ij, every three hours, as a diuretic. Coma, con- 
vulsions, and dropsy indicate jaborandi. 

Convalescence. — Basham's iron mixture, f 3 ij, ter die. Limit 
foods to skimmed milk and light, non-albuminous diet ; pro- 
hibit all spices and condiments, volatile oils and alcoholics. 

CHRONIC TUBAL NEPHRITIS. 

Synonyms. — Chronic desquamative nephritis; chronic 
Bright's disease ; large white or fatty kidney ; chronic paren- 
chymatous nephritis. 

Definition. — A chronic inflammation of the mucous lining 
of the uriniferous tubules, recognized by scanty urine of high 
specific gravity in the early stages and low in the later, with 
granular casts, epithelium, and albumin; marked dropsy, 
gastro-intestinal catarrh, and frequent attacks of uraemia. 

Etiology. — Cold, damp, intemperance, toxic malaria, syphi- 
lis, and tuberculosis. Sometimes comes from acute Bright's 
disease ; may be idiopathic ; rare in old or very young persons. 

Symptoms. — If it follows acute Bright's disease, the symp- 
toms are more chronic ; general dropsy ; effusion into serous 
cavities ; urine scanty and albuminous ; cardiac hypertrophy 
or dilatation, and a tense, wiry pulse. 

Insidious Cases. — Anaemia ; loss of appetite ; headache ; nau- 
sea ; frequent micturition and no pain in kidneys : feet cedem- 
atous at night and puffiness around eyes in morning ; dropsy 
slowly increases and causes great dyspnoea ; gastro-intestinal 
catarrh ; frequent attacks of uraemia ; retinitis albuminuria. 



270 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Urine scanty at first, but slightly increased in later stages ; 
urea diminished ; hematuria at times ; albumin nearly one 
half when boiled (two percent, to four percent, by weight) ; 
specific gravity high at first, later it is low ; tube-casts — hya- 
line, epithelial, and ' granular ; large masses of epithelial cells 
(showing fatty degeneration) ; and granular matter. Hyper- 
trophy of left ventricle of heart; slight fever at times. Sub- 
ject to pneumonia, pleurisy, peritonitis, pericarditis, bronchial 
and gastro-intestinal catarrh, oedema of lungs or glottis, 
sloughing or inflammation of skin. 

Pathology. — First Stage (large white kidney). — Kidney 
twice its normal size and weight ; capsule dull, opaque, and is 
easily stripped off ; color dull gray or red ; pyramids very red ; 
ecchymotic spots ; glomeruli and uriniferous tubules inflamed 
and stripped of epithelial lining, allowing transudation of al- 
bumin into urine. Tubes filled with epithelium, fat-globules, 
and granular masses. 

Second Stage. — Kidney rough ; nearly normal in size ; cap- 
sule adherent ; pale, white color ; bands of connective tissue ; 
degenerated kidney-cells ; tubes filled with degenerated epi- 
thelium and casts ; portions of kidney atrophied ; slight waxy 
defeneration. 

Diagnosis. — See Amyloid Kidney. 

Prognosis. — Unfavorable ; patients rarely die of the disease 
itself, but from one of its complications ; may be held in check 
many years, but is never cured. 

Treatment. — Absolute rest, and freedom from all business 
cares ; change of scene ; uniform dry temperature ; flannel 
next skin. Avoid condiments, volatile oils, alcohol, and spices. 

Diet. — Pure, sweet, skimmed milk, four to six ounces, every 
three or four hours, night and day — may be given hot; no 
other diet or drink. Vary food by adding pepsin to milk ; 
substitute whey or fresh butter-milk. Such diet diminishes 



DISEASES OF THE KIDNEYS. 271 

albuminuria, clears up vision, and aids general improvement. 
When albumin disappears, add fresh juice of orange, apple, 
or peach ; later, rice, tapioca, sago, toasted bread, and, finally, 
rare meat, eggs, or mutton. 

JVb specific medication. Opium is strictly contraindiccited on 
account of its apparently irritating action on the urinary or- 
gans. Anaemia indicates iron, arsenic, and cod-liver oil. 
Ursemic symptoms demand pilocarpus jaborandi and hydra- 
gogue cathartics. Dropsy is relieved by Basham's iron mix- 
ture, jaborandi, diuretics, and evacuants, if patient is not too 
weak. Aspiration or puncture is often followed by erysipe- 
las. Keep bowels open and active. 



CHRONIC INTERSTITIAL NEPHRITIS. 

Synonyms. — Renal cirrhosis; gouty kidney; contracted 
kidney ; cirrhotic Bright's disease. 

Definition. — A chronic inflammation of the interstitial con- 
nective tissue of the kidneys, causing a diminution in their 
size ; little or no dropsy ; increased flow of urine, albuminous 
and of low specific gravity. 

Etiology. — Grout, syphilis, lead-poisoning, alcohol, exposure, 
nervousness, and an ultimate effect of gonorrhoea. Most com- 
mon in men after fortieth year. 

Symptoms. — Begins insidiously, without symptoms to indi- 
cate kidney trouble. Later, there is frequent urination, ver- 
tigo, palpitation of heart, uneasiness, dyspnoea, and dilatation 
of left ventricle of heart. Pulse full, tense, and bounding j in- 
cessant cough. Dropsy is usually absent j eyes are puffy and 
vision disordered. Nausea, vomiting, gastro-intestinal catarrh, 
diarrhoea, anaemia, debility, and headache. Ursemic symp- 
toms and convulsions ; apoplectic attacks common. 



272 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Complications. — Pneumonia, pericarditis, endocarditis, ery- 
sipelas, apoplexy, carbuncles, and uraemia. 

Urine increased ; pale in color; specific gravity low — rarely 
above 1.010° ; albumin absent or extremely small in amount ; 
urea not decreased at first ; tube-casts few, and are granular 
or fibrinous molds ; fat-globules are not constant. 

Pathology. — Kidneys reduced in size ; capsule adherent ; 
surface granular ; pyramids small and dark ; cysts may exist 
in kidney structure. There is an infiltration of leucocytes 
into the interstitial substance which form new fibrinous tissue. 
This contracts, causing shrinkage of organ, with atrophy and 
obliteration of some urinif erous tubules. Malpighian capsules 
are thick and glomeruli crowded together. Epithelial cells 
in tubules and glomeruli are degenerated 5 section of kidney 
is tough ; heart hypertrophied and vessels degenerated, hence 
the frequency of apoplexy ; atrophy of optic nerve and blind- 
ness. 

Diagnosis. — See page 273. 

Prognosis. — -Always fatal; may continue several years; 
worst form of Bright's disease. 

Treatment. — With such a poor prognosis, treatment is not 
encouraging. Saline diuretics are of little use. Avoid every 
possible cause. When first symptoms manifest themselves, 
put patient in bed between blankets and keep him there until 
symptoms subside. Nitroglycerin, gr. T £o> or potassium io- 
dide, gr. xx-xxx, daily, reduces arterial tension — the latter pre- 
venting hyperplasia. Aconite and veratrum control the heart. 
Dyspepsia indicates a mild diet ; dilute hydrocyanic acid for 
vomiting ; tincture of iron, columbo, or quinine for anaemia. 
Counter-irritation is of doubtful utility. Stimulate when in- 
dicated. Treat uraemia. 



DISEASES OF THE KIDNEYS. 



273 



AMYLOID KIDNEY. 

Synonyms. — Lardaceous or waxy degeneration of kidney ; 
albuminoid kidney ; amyloid Bright's disease. 

Definition. — A waxy degeneration of the kidney-tissues, 
usually accompanying a similar disorder in the liver and 
spleen, recognized by polyuria and waxy tube-casts. 

Etiology. — Suppuration in bones; syphilis; tuberculosis; 
cancer. 

Symptoms. — Urine increased, pale, and specific gravity low ; 
albumin marked ; urea normal or slightly diminished ; few 
tube-casts, which are pale or transparent, giving reaction with 
iodine ; marked anaemia ; liver and spleen involved ; emacia- 
tion ; sallow face ; profuse diarrhoea ; thirst ; heart not in- 
volved ; dropsy at first is slight, later it is marked. 

Pathology. — Kidneys are large, smooth, and cut like wax ; 
capsule easily separated; characteristic reddish-brown reac- 
tion with iodine. Process begins along the vessels, involves 
other structures, and causes atrophy of glomeruli and tubules. 





Diagnosis. 




Acute Tubal 
Nephritis. 


Chronic Tubal 
Nephritis. 


Chronic Intersti- 
tial Nephritis. 


Amyloid 
Kidney. 


Urine scanty. 


Urine increased. 


Urine increased. 


Urine increased. 


Albumin marked. 


Albumin marked. 


Albumin small in 
amount or ab- 
sent. 


Albumin marked. 


Blood and simple 
epithelial casts. 


Granular epithe- 
lial casts; fatty 
degeneration ; no 
blood-casts. 


Few hyaline gran- 
ular casts. 


Few transparent 
casts; give reac- 
tion with iodine. 


Dropsy extensive. 


Dropsy a promi- 
nent symptom. 


Dropsy absent or 
slight. 


Dropsy little, ex- 
cept late. 


History of acute 
onset; pain. 


Antecedent at- 
tacks; slow on- 
set. 


Slow insidious on- 
set. 


Follows wasting 
diseases and sup- 
puration. 


Uraemia. 


Uraemia. 


Uraemia. 


Uraemia absent. 


Heart functionally 
affected. 


Hypertrophy of 
left ventricle. 


Dilated left ventri- 
cle. 


Hypertrophy of 
left ventricle. 


Occurs in children 
and young adults. 


Middle-aged per- 
sons. 


After forty, in men. 


Any age. 


No retinitis. 


Retinitis albumi- 


Retinitis albumi- 


No retinitis. 




nuria. 


nuria. 





274 A SYNOPSIS OP THE PRACTICE OF MEDICINE. 

Prognosis. — Depends on canse ; if cause is removable and 
case not too far advanced, it can be checked. 

Treatment. — Remove cause, if possible ; build up patient, 
and treat as in amyloid liver. Ammonium chloride, iron 
iodide, and other iodides. 

PYELITIS. 

Synonym. — Inflammation of the pelvis of the kidney. 

Definition. — An inflammation of the mucous membrane 
of the pelvis of the kidney, acute or chronic, recognized by 
chill, fever, pain radiating to the testicle, and acid urine, turbid 
with mucus and pus. 

Etiology. — Cold; extension from bladder; gonorrhoea; 
balsams and resins. Complicates scurvy, typhoid, typhus, and 
exanthematous fevers. 

Symptoms. — Acute cases commence with rigors and fever; 
pain in lumbar region, radiating along ureter to testicle ; 
painful micturition. Urine increased or diminished; dark- 
colored ; high specific gravity ; acid reaction ; urates and chlo- 
rides lessened ; epithelial cells from pelvis of kidney ; pus and 
blood-corpu scles. 

Chronic Pyelitis. — Urine increased ; pale straw-color ; acid 
reaction; low specific gravity; marked sediment; albumin; 
pus-cells (often in long or oval plugs) ; blood and epithelial 
cells not constant, unless tubules are involved. Uraemia com- 
plicates pyelitis. 

Pathology. — Pelvic mucous membrane engorged, red, and 
covered with mucus and pus-cells ; epithelial cells are shed ; 
blood exudes. A diphtheroid membrane is often present. As 
the process continues, inflammation extends to the urinif erous 
tubules and kidney structure, causing suppuration (pyelone- 
phritis). Pus and urine may accumulate in the pelvis of the 



DISEASES OF THE KIDNEYS. 275 

kidney from obstruction of the ureter { pyonephrosis), &!&& dis- 
charge through the kidney structure or suddenly flow into the 
bladder, when obstruction is removed. Urinary calculi are 
often found in the pelvis of the kidney. 

Diagnosis. — Cystitis. — Urine is alkaline ; suprapubic ten- 
derness ; pelvic epithelium absent. In perinephritis the urine 
remains normal. 

Prognosis. — Following fevers it is good ; chronic cases are 
bad ; pyonephrosis may cause death by perforation ; kidney 
may be totally destroyed or disabled. 

Treatment. — Hygienic. — Absolute rest; plenty of alkaline, 
carbonated waters. Avoid alcohol, condiments, volatile oils, 
and irritating foods ; strict milk diet. 

Locally. — Counter-irritation ; hot fomentations ; leeches ; 
dry or wet cups. 

Internally. — Diuretics ; salol, gr. v, ter die, diminishes fever, 
alkalinizes urine, and is antiseptic ; tr. benzoin, gtt. v-x, ter 
die. Such remedies as balsam of copaiba, quinine, tannin, pix 
liquida, turpentine, iron, and lead reduce discharge of pus and 
may do some temporary good. Opium to relieve pain. In 
pyonephrosis or impacted calculi, surgical means are indicated. 



HYDRONEPHROSIS. 

Definition. — An accumulation of urine and secretions in 
the pelvis of the kidney, due to an obstruction of the ureter, 
bladder, or urethra. 

Symptoms. — Unilateral. — A tumor is found in lumbar re- 
gion, which gradually enlarges ; smooth or lobulated ; tense 
or fluctuating ; dullness on percussion ; may suddenly dimin- 
ish in size, with a copious flow of urine, due to temporary re- 
moval of the obstruction ; it soon refills. Pressure symptoms, 



276 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

such as pain, vomiting, disordered heart, and digestion. Urine 
is normal, as the other kidney performs the function of both. 

Bilateral. — Suppression of urine, uraemia, and death, if not 
relieved. Suppression of urine may not be complete. 

Pathology. — Ureter and pelvis of the kidney are greatly 
distended ; pyramids flattened ; kidney structure atrophied ; 
cyst may contain from one to three pints of fluid, and is 
sometimes lobulated and divided by septa. Fluid is pale yel- 
low ; contains albumin and pus, urea and uric acid — in fact, 
it is similar to a diluted urine. Obstruction is caused by im- 
pacted calculi ; tumors ; cancer ; cicatricial bands ; congenital, 
or due to obstruction in bladder or urethra. 

Prognosis. — Unilateral causes little or no trouble for years, 
and is not fatal unless the other kidney fails to perform its 
function. Bilateral is fatal from uraemia or primary cause, if 
not removable. 

Treatment. — Causal. — Remedy strictures of urethra, en- 
larged prostate, or retention. Tumor is lessened by aspiration 
or surgical operation. Excision (nephrectomy). Massage 
often relieves obstruction, if used over the tumor. Treat 
symptoms. 

PERINEPHRITIS. 

Definition. — An inflammation of the cellular tissue sur- 
rounding the kidney, terminating in resolution or suppuration. 

Etiology. — Blows, sprains, metastasis, extension, cold, sec- 
ondary to fevers. 

Symptoms. — Chill, high fever, and severe pain over kidney. 
Urine normal. Onset may be insidious, with a dull, sickening, 
aching pain, radiating to testicle and groin ; pain increased 
by pressure ; patient lies with leg of affected side flexed on 
abdomen ; when standing, body is inclined to affected side. 
Chills, rigors, and pj^aemic fever indicate suppuration,, with 



DISEASES OF THE KIDNEYS. 277 

formation of abscess (perinephritic abscess), that is felt as a 
tumor between the last rib and iliac crest. Pus burrows 
along lumbar muscles and opens on the back or in the groin 
under Poupart's ligament. May perforate kidney, perito- 
neum , colon, ilium, stomach, bladder, vagina, or diaphragm. 
Capsulation sometimes occurs. 

Pathology. — Begins as a simple inflammation with exuda- 
tion; septic infection and suppuration follow. Kidney is 
infiltrated with pus, and often contains numerous sinuses ; 
perinephritic tissue may be one mass of pus. Pus varies in 
character from a pure, sweet, to a very offensive, degenerated 
mass. 

Treatment. — Rest in bed ; applications of ice over kidney ; 
keep bowels active by enema ; opium for pain, and chloral for 
insomnia. Inunctions of belladonna and mercury may pre- 
vent abscess. Evacuate pus at once; sustain patient with 
quinine, iron, cod-liver oil, and very best food. 

FLOATING KIDNEY. 

Synonym. — Movable kidney. 

Description. — Floating kidney is a term given to one that 
is freely movable from its normal position, and is congenital 
or acquired. Recognized by a feeling of weight or dragging 
in loins ; sometimes pain, aggravated by walking, running, 
and jumping; relieved by recumbeut position; attacks of 
vomiting, malaise, and great tenderness at times, but they 
soon subside. Palpation of abdomen reveals a kidney-shaped 
tumor that glides from the hand and disappears ; pressure on 
this tumor causes a sickening pain reflected to testicle or ovary. 

Treatment. — Surgical. — Application of trusses or bandages. 
Nephrorrhaphy or nephrectomy. Regulate exercise and occu- 
pation. 



278 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

RENAL CANCER. 

Description. — Cancer of the kidney is primary or secondary 
and occurs in very young or old persons. Scirrhous and med- 
ullary are most common forms ; one kidney is affected and 
the other normal. An' irregular, nodulated, tender tumor in 
region of kidney ; hematuria not constant. Urine contains 
cancer-cells ; disorganized epithelial, blood, and pus cells ; al- 
bumin. Pain is variable and at times very severe, radiating 
along ureter to testicle or ovary, the loin and hypochondrium ; 
testicle not retracted. Nausea ; anorexia ; irregular bowels ; 
anaemia, emaciation, and cachexia. Death ensues in six months 
to two years, from exhaustion, hemorrhage, peritonitis, or sec- 
ondary involvement. 

Treatment. — Palliative, — Opium for pain ; tonics ; predi- 
gested food; local applications; and general symptomatic 
treatment. 

RENAL TUBERCULOSIS. 

Description. — Renal tuberculosis is not common ; primary 
or secondary ; most frequent in male adults. Tuberculous 
deposits found in cortical mass and pyramids; these break 
down and form large, yellow, cheesy masses. The urinif erous 
tubules, pelvis, and ureters become infected and ulcerate. 

Symptoms. — They may be latent for a time, but, com- 
monly, there is a dull pain in the loins, sharp and acute at 
intervals, due to obstruction of ureters by tuberculous pro- 
ducts ; kidney not enlarged. Urine contains pus, tubercular 
debris, blood, and albumin; may be ropy and ammoniacal. 
General symptoms are fever, high in evening, with morning 
remissions ; loss of flesh and appetite ; diarrhoea ; and general 
symptoms of tuberculosis. 

Prognosis. — Always fatal ; uraemic attacks common. 



DISEASES OF THE KIDNEYS. 279 

Treatment. — Palliative and Symptomatic. — Open any sus- 
pected abscess. Nephrectomy is of little value, as both organs 
are usually affected. 

RENAL CALCULI. 

Synonyms. — Gravel ; nephrolithiasis ; kidney-stones. 

Definition. — A calcareous or stone-like concretion, having 
its origin in the kidney, and giving rise to pyelitis by its local 
irritation ; renal colic by its passage along the course of the 
ureter j or no symptoms, except a brick-dust deposit in the 
urine {gravel). 

Etiology. — Most common among the poor; males; early 
and late life. The true cause of renal calculi is obscure. 

Varieties. — 1. Uric-acid stone is most common, and is oval, 
hard, smooth, or rough, reddish in color, and varies in size from 
a millet-seed to a pigeon's egg. May be single or multiple. 

2. Urates of soda or ammonium form soft, small stones ; most 
common in childhood. 

3. Calcium Oxalate. — A mulberry-shaped calculus, rough, 
very hard, dark brown, and mostly single. 

4. Calcium Phosphate. — Phosphatic stones are smooth, soft, 
friable, earthy, or chalky, and vary in size from a hemp-seed 
to a large hen's egg. 

5. Mixed calculi contain various salts in alternate layers. 
Other calculi, not commonly found, contain carbonate of 

calcium, xanthin, indigo, and other debris. 

Symptoms. — A large renal calculus may remain in the 
pelvis of the kidney for a long time without symptoms. Later, 
there are lumbar pains, increased by jarring or motion ; hem- 
aturia; pyuria and all symptoms of pyelitis, nephritis, or 
hydronephrosis. If the stones are very small, they are de- 
posited in the urine and recognized by microscope. When a 



280 



A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



large stone passes through the ureter, spasmodic contraction 
of its muscles ensues and causes renal colic. 

Renal colic begins suddenly with violent pain, increasing in 
intensity, radiating along ureter to the testicle of the same 
side and to the head of the penis, the groin, thighs, and flanks ; 
testicle of same side and the penis are retracted ; intermissions 
last but a moment, and pain returns with greater severity. 
Thighs flexed on abdomen; patient rolls and screams with 
agony, and often faints ; pulse quick and feeble 5 temperature 
slightly elevated ; nausea and vomiting ; frequent micturition ; 
urine scanty and bloody. Attack lasts one hour to two days, 
and suddenly terminates when the stone reaches the bladder. 
Stone is passed with urine or remains in bladder and forms a 
nucleus for stone. The side is tender and sore to pressure, 
with a dull, burning pain along ureter, for several days fol- 
lowing the attack. The stone may lodge in the ureter and 
cause obstruction, ulceration, peritonitis, and death. 

Pathology. — Urine becomes concentrated or greatly loaded 
with salts, which crystallize about a nucleus of pus, mucus, 
epithelium, or blood, and form a stone. When the crystals 
do not form about a common nucleus it causes gravel. 



Renal Colic. 

On either side. 

Pain reflected to tes- 
ticle, head of penis, 
with retraction ; uri- 
nary symptoms. 

Not relieved by press- 
ure. 

Passage of renal stone. 



Diagnosis. 

Hepatic Colic 

Always on right side. 

Pain reflected to back, 
shoulder, and no 
urinary symptoms ; 
slight jaundice. 

Not relieved by press- 
ure. 

Passage of srall stone. 



Intestinal Colic 

Over whole abdomen ; 
umbilical. 

Pain central over um- 
bilicus ; no urinary 
symptoms or jaun- 
dice. 

Slight relief from press- 
ure. 

Passage of indigested 
food. 



Prognosis. — Must be guarded, as many sequela^ or compli- 



cations arise. Simple gravel is curable. 



Large stones cause 



DISEASES OF THE KIDNEYS. 281 

py elitis, hydronephrosis, nephritis, obstruction of ureter, stone 
in bladder, uraemia, or death. 

Treatment. — Renal Colic. — Hypodermic injection of mor- 
phina and atrophia for pain • inhalations of chloroform, ether, 
or bromide of ethyl for anaesthetic effect ; hot applications, 
posteriorly, along course of ureter. Antispasmodic and relax- 
ing remedies, such as tartar emetic, morphina, and anaesthet- 
ics, favor passage of stone. Subsequent symptoms, tender- 
ness and pain, are best relieved by hot applications, alkaline 
diuretics, and morphina. 

Preventive. — Limit amount of nitrogenous food to prevent 
formation of uric acid ; give milk, vegetables, and large amounts 
of alkaline, diuretic waters ; extractum pichi fluidum alkali- 
nizes urine, and is valuable ; keep emunctories active j frequent 
baths and exercise. Phosphatic and oxalic calculi require 
ammonium benzoate or nitromuriatic acid and free diuresis. 
Impacted calculus necessitates snrgical measures. The so- 
called solvent remedies prevent the stone from becoming 
larger (?), but their solvent action is extremely doubtful. Pipe- 
razine, gr. v-xv, daily, is the best remedy now known for 
calculi or gravel ; a one or two percent, solution, injected into 
the bladder, may dissolve a calculus if long continued. 

RENAL PARASITES. 

The three principal classes of parasites that invade the uri- 
nary organs deserve mention, owing to the frequency with 
which they are met in certain countries. 

(1) Filaria Sanguinis Hominis. 

Description. — A filiform or thread-like worm, about three 
inches long j indigenous to the countries of China and India, 
It enters the lymph-channels and blood-vessels ; affects differ- 
ent organs j causes elephantiasis of the scrotum, lymphangitis, 



282 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

or chyluria. How chyluria is caused by this parasite is not 
positively explained. Urine is milky ; white ; fat collects on 
its surface ; small amount of blood or albumin ; and the filaria 
can often be detected with microscope. It may last for thirty 
years, with emaciation, great thirst, little fever, and an un- 
natural appetite. 

Treatment. — Little can be done for it. Preventive treat- 
ment consists in using boiled water and thoroughly cooked 
foods. Thymol, gr. j, increased to gr. v, ter die, is said to have 
cured two typical cases. 

(2) Echinococcus Hominis. 

Description. — Hydatids of the kidney are produced like hy- 
datids of the liver, and vary in size. The only symptom pres- 
ent may be a tense tumor in the loin, that gives a peculiar 
thrill on percussion. Rupture of the cyst is common; renal 
colic from passage of small cysts, pyelitis, cystitis, or suppu- 
ration complicate. May last many years. Prognosis is not 
bad. 

Treatment. — Aspirate cysts or perform nephrotomy. Treat 
symptoms. 

(3) BlLHARZIA ILeMATOBIA. 

Description. — A fluke-like worm, varying in size from 
one half to three quarters of an inch in length ; female is the 
larger; inhabits waters of Egypt, and is most common in 
those who bathe in the streams. Parasite invades mucous 
membrane of urethra, bladder, ureters, and pelvis of kidney. 
Heematuria, following passage of clear urine, is the leading 
symptom ; pain in loins, and anaemia. Prognosis is good. 

Treatment. — Alkaline, diuretic waters ; oil of turpentine 
and chloroform, internally ; salol, gr. v, ter die. Washing out 
the bladder is of questionable value. 



DISEASES OF THE BLADDER. 

CYSTITIS. 

Synonym. — Catarrh of the bladder. 

Definition. — An acute or chronic inflammation of the mu- 
cous membrane of the bladder, accompanied by scanty, alka- 
line, ropy urine, hypogastric pain, slight fever, and tenesmus. 
Varieties are catarrhal, diphtheritic, and croupous. 

Etiology. — Acute. — Unskillful or careless injections or cath- 
eterization with septic instruments ; direct injuries or blows ; 
cold ; foreign bodies ; calculi ; retention or acidity of urine ; 
new beer ; extension of gonorrhoea or pyelitis ; fevers ; diph- 
theria ; nervous disorders ; and irritating medicines. 

Chronic. — Comes from acute ; enlarged prostate ; stricture 
of urethra ; stone in bladder ; cancer ; tuberculosis ; tumors ; 
kidney-diseases ; old age ; and Bright' s disease. 

Symptoms. — Acute. — Weight and pain in hypogastrium 
and perineum, increased by pressure, and radiates to back and 
groins ; chills ; loss of appetite ; some fever ; irritable bladder ; 
vesical tenesmus 5 urine passed in small amount after great 
tenesmus ; burning micturition. Urine is high-colored, cloudy, 
ropy, alkaline, and contains mucus, pus, epithelium, and blood- 
cells. 

Chronic, — Most common in old men with enlarged prostate. 
Begins gradually with tenderness in the hypogastrium ; fre- 
quent scanty micturition, with tenesmus ; loss of appetite ; 
gastro-intestinal catarrh ; bad breath ; general debility. Ul- 
ceration is indicated by severe burning pain, hematuria, 
pyuria, and hectic fever. Urine scanty, alkaline, contains 

283 



284 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

offensive muco-pus, and deposits crystals of the triple phos- 
phates, pus, mucus, blood, and epithelial cells. When bladder 
becomes hypertrophied, a hard tumor is felt above the pubes j 
urine dribbles, and cannot be retained. 

Pathology. — Acute. — Hyperemia of mucous membrane, 
most marked in the vesical triangle ; membrane red, swollen, 
and oedematous ; increased glandular secretion j desquamated 
epithelium ; small ulcers or erosions, covered with mucus and 
pus. Submucous abscesses form; sinuses. A diphtheritic 
membrane may exist. 

Chronic. — Membrane is gray or bluish, thick, tough, and 
covered with a thick, decomposing, alkaline mucus and pus j 
bacteria present. Mucous membrane is ribbed, giving a co- 
lumnar appearance ; walls of bladder may be one-half to one 
inch thick. Hypertrophy is concentric or" acentric. Perforat- 
ing abscesses and sinuses. 

Diagnosis. — Neuralgia has a sharp, lancinating pain, no 
fever or urinary symptoms, and lasts a few hours. Uterine 
and vaginal troubles diagnosed by examination. Pyelitis has 
lumbar pains, following ureters; acid urine and no vesical 
tenesmus. 

Prognosis — Acute cases usually recover. Chronic cases 
drag on for years, and when hypertrophy occurs they are in- 
curable. 

Treatment. — Acute. — Remove cause. When due to cold, 
diaphoretics, leeches, hot poultices or fomentations to peri- 
neum and hypogastrium, rectal injections of hot water, hot 
baths, and rest in bed. Avoid condiments, volatile oils, alcohol, 
salt, and acids. Alkaline waters in large quantities diminish 
irritability ; camphor relieves catarrh of cantharides. Dover's 
powder, opium, belladonna, or Cannabis Indica relieve tenes- 
mus. Salol, gr. v, ter die, benzoic acid, infusion of pareira 
or extractum pichi fluidum, gtt. x, in brandy, every two hours, 



DISEASES OF THE BLADDER. 285 

constitute valuable remedies. Milk diet is most suitable. 
Keep bowels open and treat symptoms. 

Chronic. — Empty bladder at regular intervals with a smooth, 
soft, elastic catheter. Absolute rest in bed. Copaiba relieves 
secretion of mucus and pus temporarily, but does not cure, 
for, as soon as discontinued, the trouble returns. Germicidal 
treatment is a failure, because antiseptic solutions cannot be used 
sufficiently strong on account of their great irritation. Large 
quantities of alkaline waters internally. A peculiarity with 
these cases is the fact that all food tires them, and the only 
diet that seems to be acceptable is highly seasoned terrapin. 
After all, the best remedy is washing out of the bladder. Bichlo- 
ride of mercury, sulphocarbolates, zinc sulphate, silver nitrate, 
and tannic acid are too irritating for injections. Creolin, 
one to two thousand, is recommended. One of the best and 
safest injections is one tablespoonful of hamamelis to a pint 
of warm water. Injections should be given with a douche (not 
a syringe), without any force. Discomfort during injections 
means that the solution is too hot or cold, too strong, or too 
much force. Wash through a two-way catheter until return- 
flow is clear ; always allow some of the fluid to remain in 
bladder. Strengthen with iron and cod-liver oil. Salol and 
pichi do good in some cases. 

HYPERESTHESIA OF THE BLADDER. 

Description. — A neurosis, characterized by constant desire 
to micturate ; no lesion to the bladder-walls. Due to acidity of 
urine ; sexual excesses ; increased solid constituents of urine ; 
onanism j gonorrhoea ; and masturbation. Flow of urine is 
weak, and causes straining; desire to urinate every fifteen 
minutes or more ; pain reflected to glans penis. Often com- 
plicated by pruritis ani. 



286 A SYNOPSIS OP THE PRACTICE OF MEDICINE. 

Treatment.— Cold douches to spine; salt-water baths; 
Turkish baths. Severe eases relieved by balsam copaiba, or, 
better still, compound tincture of benzoin, gtt. xv-xx, ter die. 
Praritis ani relieved by penciling cutaneous margin of anus 
— not the mucous membrane — with benzoin. Alkalies for 
hyperacidity ; oxide of zinc relieves hyperesthesia of urethra. 
Break up habit of masturbation or excessive venereal excesses. 
Treat cause. 

ANESTHESIA OF THE BLADDER. 

Synonyms. — Nocturnal incontinence of urine ; enuresis. 

Description. — An inability to retain urine during sleep, 
most common in children. Caused by irritation of intestinal 
worms ; kidney-disease ; phymosis or adherent prepuce ; con- 
stipation ; uncleanliness ; excessive use of liquids before re- 
tiring ; and dorsal position during sleep. If not checked, it 
ultimately leads to confirmed masturbation ; hyperesthesia of 
prostate ; spermatorrhoea ; hypochondria ; insanity ; neuras- 
thenia ; and, finally, locomotor ataxia. Urine constantly drib- 
bles, and is voided during sleep. Privates are very irritable. 

Treatment. — Absolute cleanliness; operate on congenital 
defects of privates ; remove cause ; forbid drinking before retir- 
ing ; make child get up during night and early morning to uri- 
nate, and before retiring. Cause the child to sleep on its side 
by placing some substance on the back, such as a ball or book. 
Insist on out-door exercise in pure, fresh air ; athletic sports ; 
horseback riding ; salt baths every morning ; flannel next skin. 
If child is a masturbator, keep it employed and under constant 
observation. Iron is good in anaemia or worms. Erigeron, 
cantharides, or nux vomica overcome weakness of sphincters. 
Tincture of belladonna, bromides, and chloral may do good if 
pushed to point of tolerance. Tr. gelsemii, gtt. v, before re- 



DISEASES OF THE BLADDER, 287 

tiring, and small doses during the day, is claimed to be very 
valuable. Electricity, applied to sphincters, increases tone, 
and is a means of cure. 

HEMATURIA. 

Description. — Blood in the urine is symptomatic of trouble 
in the urethra, prostate, bladder, ureters, or kidney j or second- 
ary to some constitutional disorder. It is due to Bright's 
disease ; active or passive renal congestion ; renal calculi ; 
abscess j ulcer ; cancer ; tuberculosis • entozoa ; purpura ; ma- 
laria ; vicarious menstruation ; use of irritant medicines. 

Blood from kidneys is indicated by smoky urine, with casts 
of uriniferous tubules and symptoms of renal colic. Blood 
from bladder follows the passage of urine, and is pure or clotted ; 
may be mixed with urine. Hemorrhage from urethra is inde- 
pendent of micturition. Endemic Jiwmaturia occurs in Brazil, 
Egypt, and Cape Colony from the parasite Bilharzia hcema- 
tobia. (See page 282.) 

Treatment. — Causal. — In general, rest in bed ; cold appli- 
cations ; injections of ice-water into rectum ; oil of erigeron, 
gtt. v, ter die ; ergot ; tannic acid ; gallic acid ; tr. f erri chloridi. 
Hemorrhage from these organs is rarely fatal, as the capacity 
of the bladder limits flow of blood. Maintain strength and 
treat on the general principle indicated by cause. 

PARALYSIS OF THE BLADDER. 

Description. — Paralysis of the bladder is due to cerebral 
disease (least common form) ; paralysis of the detursor urinae 
muscle ; peripheral lesions ; prolonged over-distention from 
retained urine ; rarely found in typhus or typhoid fever. 
Complete paralysis of the sphincter causes dribbling. If the 



288 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

sphincter and detursor urina? muscles are paralyzed, the blad- 
der is always full, and urine constantly dribbles ; hence the 
term incontinence with retention. 

Treatment. — Use catheter at regular intervals, three or four 
times a day. If there is prolonged retention, never remove all 
urine at once, but allow a small amount to escape at a time, so 
that the bladder-walls may be supported until they regain 
their muscular tone. Galvanism to bladder and involuntary 
sphincter. Strychnina in full doses, gr. -^- 6 , ter die, increased 
to tolerance ; cold baths. Paralysis of bladder sphincter 
alone is relieved by oil of erigeron. Treat cause. 



PHYSICAL DIAGNOSIS. 



INTRODUCTION. 

Physical Diagnosis. — A method of distinguishing, fixing, 
or interpreting a disease from symptoms which are recognized 
by our senses. 

Differential Diagnosis. — " The qualitative distinguishing 
between two distinct diseases of similar character by compara- 
tive symptoms." (Gould.) 

Physical Signs. — The indications or results obtained by 
inspection, mensuration, palpation, percussion, auscultation, 
and succussion. 

Topographical Anatomy. — The study of external land- 
marks or points which indicate or determine the comparative 
location of the various organs and parts of the body. Certain 
landmarks on the chest-walls are used as fixed points, and, 
from these, subdivisions are made for convenience in study 
aud to avoid confusing terms. The clavicle, nipples, sternum, 
axilla, scapula, spinous processes of the vertebrge, and ribs 
constitute the fixed points, and all signs should be given with 
reference to them. To be accurate in this reference, it will 
be necessary for the patient to sit or stand erect with the parts 
in full view ; or, if lying down, to assume a natural, comfort- 
able position, so that none of the muscles of the parts may be 
brought into action and mask any important points. 

289 



290 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

INSPECTION. 

Inspection of the chest means simply looking at it from all 
sides. The normal movements of the chest vary in the sexes. 
The abdominal or inferior costal type of respiration is character- 
istic of the male sex and children. Movement of the chest in 
its upper portions, superior costal breathing, is characteristic 
of the female. The chest shonld be full, round, and nearly 
symmetrical. Respiratory movements in health are between 
sixteen and twenty per minute, and regular in rhythm. By 
inspection we determine whether the chest is deformed; 
whether the intercostal spaces are suuken or bulging j whether 
there is supra- or infra-clavicular depression, retracted or ex- 
panded chest- walls. We also note any discoloration, tumors, 
apex-beat of the heart, or unilateral motion of the chest. 

MENSURATION. 

The average normal circumference of the chest above the nip- 
ples is thirty- three inches. The difference between forced in- 
spiration and forced expiration (expansion) is about two inches 
in health. In comparing the two sides of the chest, mark the 
median line anteriorly and the spinous processes of the verte- 
brae posteriorly. The two sides vary according to a right or 
left-handed person. The side most used is larger, by one-half 
inch, than the other. Accurate measurements are taken when 
the breath is held between forced expiration and forced inspi- 
ration. Molding soft strips of lead to the side enables one to 
compare the chest from week to week and notice any retrac- 
tion or expansion. 

The spirometer is used to determine the capacity of the 
lungs, but there are so many sources of error in its use that 
it is not an accurate means of diagnosis. 



PHYSICAL DIAGNOSIS. 291 

PALPATION. 

A method of examining the chest by the fingers or the 
hands. By it we learn of its movements, size, and form; 
points of tenderness or tnmors ; vocal fremitus, vibrations, 
and ronchi. Fremitus is a vibration of the chest- walls, most 
marked in those who have deep bass voices, consolidation, or 
roughened pleura. It is produced by crying, talking, cough- 
ing, or deep breathing. Normal fremitus is felt all over the 
chest, most marked at the right apex. Consolidation in- 
creases, pleural effusion diminishes, fremitus. 

PERCUSSION. 

The act of striking any portion of the body, with the object 
of learning pathological conditions by the resonance of the 
strokes. It is made by means of the fingers (immediate per- 
cussion), or by some instrument interposed, as a pleximeter 
(mediate percussion). Percussion is said to be clear, tympanitic, 
or dull ; and differs in pitch, strength, and duration. 

Clear sounds are produced over tissues that contain air — 
usually referred to the lungs — and indicate a normal con- 
dition. 

Tympanitic sounds are those produced over the intestines 
or cavities containing a large amount of gas or air. These 
sounds have been likened to a metallic or amphoric sound, be- 
cause they are produced in large cavities with tense walls ; 
and the cracked-metal or cracked-pot sound in cavities connect- 
ing with a bronchial tube. 

Dull sounds are elicited by percussion over liquids, solid 
matter, and such organs as the liver, spleen, or heart. Con- 
solidated lung-tissue gives dullness and a sense of resistance 
to the finger used in percussing. 



292 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Respiratory percussion is practiced during forced inspiration 
and expiration, and is of value in detecting any points that 
might be overlooked in ordinary percussion. 

AUSCULTATION. 

A process of listening to the sounds produced in the various 
organs, with a view of comparing or harmonizing them with 
the symptoms obtained by other methods, and thus arrive at 
a more accurate diagnosis. Immediate auscultation is practiced 
by placing the ear directly in contact with the skin over the 
organ. Mediate auscultation is the intervention of some sub- 
stance between the ear and parts — most commonly a stetho- 
scope. Never practice auscultation with the head too low ; in 
uncomfortable positions ; through thick clothing ; nor under con- 
ditions of noise or personal excitement. It reveals to us the 
sounds of respiration 5 the voice ; coughing ; healthy and un- 
healthy conditions. 

Tubular or bronchial breathing is a sound similar to that 
produced by blowing through a tube, and is present in the 
trachea and large bronchi, both on inspiration and expiration. 

Vesicular murmur is heard over the lungs, marked on in- 
spiration, less distinct on expiration. It is soft, low in pitch, 
and caused by the expansion and contraction of the air- vesi- 
cles, cells, and small bronchi. It differs in different parts of 
the lungs, and is affected by disease. Vesicular murmur may 
be increased in duration and intensity (puerile respiration); 
may be very feeble, from obstruction of tubes, debility, me- 
chanical pressure, intervention of fluids, or consolidations ; 
may be absent, from complete obliteration or obstruction of 
air- vesicles or bronchial tubes, or the presence of large amounts 
of fluid. Jerking inspiration is due to the neurotic element 
in tuberculosis and hysteria. 



PHYSICAL .DIAGNOSIS. 293 

Bronchial respiration alone is indicative of consolidation 
from infiltration, effusions, or new growths, and is tubular in 
character. 

Cavernous respiration is a blowing, hollow sound ; low pitch • 
circumscribed ; gurgling ; and indicative of cavities or dilated, 
large bronchi. 

Amphoric respiration is caused by a cavity with thick, tense 
walls, and produces a metallic sound like that of blowing 
into an empty bottle. 

Cheyne- Stokes Respiration. — "A phenomenon observed in a 
form of dyspnoea, in which there is a rhythmical increase of 
the respirations up to a certain degree of rapidity, then gradu- 
ally decreasing again to a temporary cessation." (Gould.) 

Rale. — A rattling sound produced by the passage of air 
through obstructions of the bronchi and lungs, either moist 
or dry in character. It occurs during expiration, inspira- 
tion, or both. 

Moist rales are produced by air passing through liquids in 
the bronchi or lungs, and cause a bubbling sound. 

Dry rales are the result of air passing through tough, tena- 
cious exudation or a partial obstruction to the caliber of the 
bronchi or lungs. 

Cavernous rales are heard over cavities containing liquid, 
and are caused by a bubbling of air through it. Present in 
last stages of phthisis pulmonalis. 

Crepitant or Vesicular Rales. — Fine, crackling sounds, simi- 
lar to that caused by rolling hair between the fingers, and 
heard at the end of expiration. Present in the first stages of 
pneumonia and incipient phthisis. 

Mucous Rales. — Bubbling sounds caused in the bronchial 
tubes by air passing through mucus. 

Sibilant rales are sharp, hissing, whistling sounds heard in 
narrowing of the small bronchi. 



294 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Sonorous rales are harsh, snoring-like, low-pitched sounds 
due to narrowing of the large bronchi. 

Tracheal or subcrepitant rales are made by air passing 
through an accumulation of mucus in the trachea, and often 
termed the death-rattle. 

Friction-sounds arise from rubbing together of the rough- 
ened surfaces of the pleura on inspiration and expiration, and 
are dry or moist. Heard in pleurisy. 

THE VOICE. 

The voice varies under conditions of health and disease, and 
can be heard as the vocal resonance ; more marked on the 
right side of the chest. 

Bronchophony. — The resonance of the voice as heard in the 
bronchi (concentrated near the ear), indicative of consolidation 
of pneumonia and phthisis. 

Pectoriloquy. — A peculiar resonance of the voice over a cav- 
ity or complete consolidation, by which every articulate word 
can be distinctly recognized. 

JEgophony. — A tremulousness of the voice similar to the 
sound made by a bleating goat (a nasal-like twang), indicative 
of pleural effusion or pleuro-pneumonia. 

Vocal resonance may be diminished, increased, or absent. 
When the patient whispers, similar changes are noticed as in 
spoken voice. 

SUCCUSSION. 

A process of shaking or lightly striking the chest-wall with 
the purpose of eliciting a splashing sound or wave, which is 
best heard when the ear is placed against the chest, and indi- 
cates the presence of fluid in the pleural cavity. Present in 
hydrothorax or pneumo-hydrothorax. 



DISEASES OF THE NOSE. 

ACUTE RHINITIS. 

Synonyms. — Acute nasal catarrh ; cold in the head ; acute 
coryza. 

Definition. — An acute inflammation of the Schneiderian 
mucous membrane, extending by continuity of structure to 
the lachrymal duct, conjunctiva, pharynx, and other cavities 
with which it is connected. 

Etiology. — Exposure to cold ; irritating vapors ; chemical 
fumes or dust; epidemic; predisposition. Complicates and 
is symptomatic of measles, syphilis, and influenza. Follows 
the excessive use of potassium iodide. 

Symptoms. — Begins with repeated sneezing, chilliness, and, 
in children, some fever. Nose is dry, " stuffed up," and articu- 
lation impaired ; mucous membrane red and swollen ; nasal 
breathing impaired; sense of taste and smell diminished or 
lost temporarily. Very soon a profuse, watery, salty, thin 
fluid begins to flow from the nose and excoriates the upper 
lip and anterior nares. Headache, dull and severe, when 
frontal sinuses are involved ; dull, heavy feeling ; eyes suffused 
with tears, from extension of inflammation through the lach- 
rymal duct ; hearing dull, from extension or closure of Eusta- 
chian tube. Catarrh may leave suddenly or the discharge 
will assume a muco-purulent character and acute symptoms 
subside gradually. Severe cases involve the pharynx, larynx, 
and lungs, giving a u naso-pharyngo-laryngo-broncho-pul- 
monary catarrh." 

Prognosis — Mild cases recover in two days to one week. 

295 



296 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Severe cases may run for weeks and terminate in chronic nasal 
catarrh j or, by extension, diseases of the ear, lachrymal ap- 
paratus, pharynx, bronchial tubes, lungs, mastoid cells, an- 
trum, or frontal sinuses. 

Treatment. — Preventive. — Avoid all causes. When it is 
necessary to work in dust or irritating vapors, wear a wet 
sponge-respirator. Harden the body by cold sponging, and 
avoid any influence that would tend to debilitate or increase 
susceptibility to cold. 

Acute Attack. — If seen early, give pulvis ipecacuanhae et 
opii, gr. v-x, at bedtime, with a hot drink to promote free 
diaphoresis ; or a hot Turkish bath, followed by rest in a warm 
room. One drop of tr. aconiti or tr. veratri, every hour, until 
the physiological effects are obtained j tr. belladonnas or atro- 
pine sulphas will check excessive secretion ; quinine is recom- 
mended by some, but is not sufficiently active to abort acute 
attacks. 

Local applications of very dilute acidum carbolicum and 
sodii chloridum by means of a spray or douche j unguentum 
petrolii used freely ; menthol inhalations ; powders of bismuthi 
salicylas with morphines sulphas ; sprays of hydrogen peroxide 
(one to eight of water) ; four-percent, solution of cocainge hy- 
drochloras relieves sneezing and congestion temporarily. 

Symptomatic catarrh must be treated according to cause. 
" Sniffles n in new-born children usually indicates syphilitic in- 
fection, and demands specific treatment and mild errhines. 
Arsenic in small doses is said to relieve prolonged attacks 
when other remedies fail. 

CHRONIC RHINITIS. 

Synonym s. — Chronic nasal catarrh ; chronic coryza. 
Definition. — A chronic inflammation of the Schneiderian 



DISEASES OF THE NOSE. 297 

mucous membrane, presenting itself in the form of a dry or 
moist catarrh. 

Etiology. — A sequel of acute rhinitis; syphilis; tubercu- 
losis ; constant irritation. 

Symptoms. — Dry Rhinitis. — Characterized by a dry, burning 
feeling and fullness in the nose and frontal sinuses ; obstructed 
nasal breathing ; little discharge, except occasional dry scabs, 
tough mucus, or blood ; epistaxis ; nasal voice ; impaired or 
destroyed sense of smell ; ulcerated patches ; slight cough ; and 
desire to clear the nose. Acute exacerbations are common. 
It is the most common cause of lachrymal obstruction. 

Moist Rhinitis. — Characterized by a free flow of mucus, 
greenish or yellow muco-pus, which is either blown from the 
anterior or drawn through the posterior nares, hawked, and 
expectorated. Constant desire to hawk and clear the throat 
caused by the secretions dripping from the posterior nares ; 
obstructed breathing ; breath offensive at times, more marked 
in the morning ; impaired sense of smell and taste ; occasional 
epistaxis. 

Ozena, sometimes termed chronic rhinitis ( f ), is a condition 
where the mucous and submucous tissues are thickened and 
ulcerated; the turbinated bones necrosed, and at times ex- 
posed. Odor is fetid, penetrating, and so offensive that it is 
noticed several feet from the patient. Discharge is thin, con- 
tains bloody mucus or muco-pus, and is very offensive. 

Pathology. — Mucous membrane is hypertrophied, infil- 
trated, dark red or grayish, and swollen ; scabs of dry, in- 
spissated mucus, serum, and pus; an increased glandular 
secretion in the moist, decreased in the dry, form; small 
ulcers at times, that may leave the bone exposed and cause 
necrosis ; veins enlarged and dilated. Occasional occlusion 
of nares by polypi. The tissues, being of an erectile structure, 
cause temporary occlusion of nares under slight irritation. 



298 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Septum may be perforated. Catarrh extends to the lachrymal 
duct, causing stricture and epiphora. Pathology of ozena is 
not definitely settled. 

Prognosis. — Perfect cures are rare. Long, persistent treat- 
ment, change of climate and occupation may result in tem- 
porary or, possibly, permanent cure. 

Treatment. — Constitutional. — Treat all diatheses and give 
tonics. Stryehninae arsenias, gr. T io, ter die. Alteratives, 
potassium iodide and mercury, increased to tolerance, pro- 
mote absorption of hypertrophic tissues. 

Local. — It is impossible to make thorough applications to 
the entire tortuous Schneiderian mucous membrane ; hence the 
inefficiency of nasal douches and insufflations, which only 
reach the inferior, middle, and part of the superior meatus. 
Cleanliness is the main principle. To accomplish this, use 
weak solutions of sodii chloridum or sodii bicarbonas, with a 
douche, post-nasal spray, or, better still, snuffing it from the 
palm of the hand. A valuable application or spray is hydro- 
gen peroxide or tr. iodini comp. (see Pharyngitis). This can 
be followed by powders of aristol, iodoform, bismuthi sali- 
cylas, or morphina. Local applications to ulcers, such as 
dilute acidum nitricum, zinci chloridum, or argenti nitras. 

Mastic nasal tubes are now worn to promote absorption of 
hypertrophic tissues ; galvano-cautery or surgical measures are 
used to remove hypertrophied, turbinated bones. 

HAY-FEVER. 

Description. — A disease (?) or peculiar hyperaesthetic con- 
dition (neurotic ?) of the Schneiderian and bronchial mucous 
membranes, characterized by yearly attacks, which come dur- 
ing the season when the air is laden with pollen of grains, 
grasses, and certain flowers. Begins suddenly with constant 



DISEASES OP THE NOSE. 299 

sneezing ; free flow of a clear mucus from the nose ; conges- 
tion of eyes and nasal mucous membrane ; obstruction to 
nasal breathing ; secretions become thick, purulent, or bloody. 
Catarrh may extend to larynx and bronchi, with coughing 
and asthmatic attacks. Lasts from one day to several weeks ; 
leaves patient weak and miserable. Is most common in 
males, after puberty, and in those who live in cities. Often 
complicated by bronchitis, oedema of the lungs, or pneumonia. 
Such terms as summer catarrh, rose-cold, and rose-fever are 
applied to it. 

Treatment. — Very unsatisfactory. Change of climate to 
sea-shore or mountains ; remain indoors during the middle 
hours of the day ; avoid passing or coming in contact with 
any of the pollen-bearing cereals or flowers. Free inhalations 
from a menthol inhaler or menthol spray greatly mitigate at- 
tacks of sneezing and irritation. Ammonia; cocaine, four- 
percent, solution ; carbolic acid, and tr. benzoini comp., locally, 
afford partial relief. Atropina is indicated by profuse watery 
discharge. Remove hypertrophied turbinated bones and mu- 
cous membrane by galvano-cautery or other surgical means. 
Quinina ; phenacetin ; acetanilide ; potassii iodidum ; arsenic ; 
and antispasmodics constitute internal medication, but do little 
good. Treat bronchial catarrh and asthma as indicated under 
those diseases. 



DISEASES OF THE LARYNX. 



ACUTE CATAERHAL LARYNGITIS. 

Definition. — An acute catarrhal inflammation of the laryn- 
geal mncons membrane, accompanied by sore throat, painful 
deglutition, dry, hacking cough; and impaired function of 
speech. 

Etiology. — Exposure to cold ; inhalation of irritating va- 
pors and chemical fumes; prolonged use of the voice in 
speaking or singing; direct injury; predisposition. Symp- 
tomatic of measles. 

Symptoms. — Begins with chill, rigors, and some fever ; or 
comes on gradually with a dry, burning, tickling sensation in 
the larynx; constant desire to cough and clear the throat; 
hoarseness, that gradually increases until patient cannot artic- 
ulate (aphonia) ; slight pain on deglutition ; some fever and 
dyspnoea in severe cases. Cough is first dry and harsh, but 
soon becomes loose — and plugs of mucus, streaked with blood, 
are coughed up — then muco-purulent, and gradually subsides 
or becomes chronic. 

Pathology. — Mucous membrane covering the larynx and 
vocal cords red, congested, and, in places, small abraded 
patches, with slight hemorrhage. Vocal bands do not approx- 
imate properly, hence the loss of voice. Secretion is first 
thick and tenacious, but soon changes to a muco-purulent 
character, and is more easily expectorated. 

300 






DISEASES OF THE LARYNX. 301 

Prognosis. — Does not result fatally ; may become chronic ; 
lasts from a few days to three weeks. 

Treatment. — Preventive. — Harden patient by cold baths; 
cold sponge-baths, followed by free friction. Avoid hot baths, 
close confinement, sudden changes of clothing or temperature, 
or anything that would tend to effeminacy. 

Onset. — Give tr. aconiti or tr. veratri in full doses, every 
half -hour, until fever is broken. Hydrargyri chloridum 
mite, gr. to, every hour, until it opens bowels freely. Keep 
patient in a moist air at a uniform temperature. Inhalations 
of medicated steam (tr. benzoini comp., carbolic acid, or oleum 
eucalyptol). Limit amount of fluid taken. Pulvis ipecac- 
uanha et opii, gr. i-ij, every hour, until cough is broken or 
soothed. Apply cold or hot compresses over the throat. 
Small doses of codeina will soothe cough. When acute stage 
is passed, give small doses of antimonii et potassii tart., 
gr. A? syr. ipecacuanhae, or syr. scillge. 

Antimonii et potassii tart gr. j. 

Potassii bromidi 3 jss. 

Syr. aurantii floratis f § j. 

Liq. ammonii acetatis q. s. ad. f 1 iij. 

M. Signa. One teaspoonful every two or three hours. 

(EDEMA OF THE GLOTTIS. 

Description.— An inflammation of the mucous membrane 
of the glottis and larynx, accompanied by an infiltration of 
serum into the loose areolar tissue, causing oedema. Occurs 
in young adults from exposure to cold, septic fevers, Bright's 
disease, syphilis, and tuberculosis. Begins in a few hours 
with hoarseness; dry cough and marked dyspnoea; pain in 
the throat ; sense of fullness ; difficult and painful deglutition, 



302 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

The swollen epiglottis often projects above the base of the 
tongue, or can be felt with the finger. Fatal dyspnoea may 
occur if not properly managed. 

Prognosis. — Many cases recover, but it is a serious disease. 

Treatment. — Scarify the swollen epiglottis freely and fre- 
quently : this will fulfill every indication. Tracheotomy may 
be indicated. Tr. aconiti for fever; brisk, drastic cathar- 
tics; and free diaphoresis with pilocarpine and hot drinks. 
Limit as far as possible the amount of water taken ; leeches 
to the neck. Emetics are indicated by rales in the chest. 
Attend to all constitutional disturbances, and treat all symp- 
toms as indicated. 

CHRONIC CATARRHAL LARYNGITIS. 

Description. — A chronic inflammation of the laryngeal mu- 
cous membrane, due to repeated acute attacks j excessive or 
improper use of the voice ; smoking ; alcohol ; syphilis ; all irri- 
tating chemical fumes ; and dust. Voice is hoarse ; dryness 
and tickling sensation in the throat, with a desire to cough 
or clear it, especially before beginning to speak. May not 
cause any trouble for several days, and then be aggravated 
by slight cause. Acute exacerbations are frequent. Laryn- 
goscopic examination shows a congested . mucous membrane, 
covered by tenacious mucus; swelling and thickening at 
times ; small ulcers or erosions ; improper approximation of 
vocal bands in phonation. 

Treatment. — Constitutional. — Build up the patient with 
tonics and good food ; abstain from smoking and drinking ; 
and use the voice as little as possible. Avoid every cause. 
Alteratives may be indicated. Strychnines arsenias, gr. T ^o? 
ter die. 

Local — Inhalations of medicated steam to remove tenacious 



DISEASES OF THE LARYNX. 303 

mucus. Apply, with a laryngeal spray or brush, solutions of 
zinci chloridum, gr. xx-xxx to the 5 j of water; hydrogen 
peroxide ; alum ; zinci sulphas, gr. x-f 1 j ; glycerol of tannin. 
Topical applications of iodoform, aristol, or pyoctanin are 
recommended. Treat ulcers by direct application of caustics. 
Electricity aids in restoration of muscular tone. Small doses 
of ammonii murias and codeina will relieve the obstinate 
tickling and tendency to cough. 

TUBERCULAR LARYNGITIS. 

Description. — Tubercular laryngitis, or laryngeal phthisis, 
is secondary to general tuberculosis, and rarely primary. 
Most common in males and rarely found in childhood. Voice 
becomes weak, hoarse, and is finally lost; pain on every 
attempt at swallowing or speaking ; a weak cough. Late in 
the disease, food enters the larynx and trachea, causing violent 
paroxysms of coughing ; food cannot be swallowed, owing to 
paralysis of the pharyngeal muscles. Laryngoscope shows 
tuberculous infiltration around the vocal cords ; ulcers, which 
are limited or involve the whole cord ; small tubercles. 

Constitutional symptoms are usually present, such as fever ; 
dullness at apex of one or both lungs ; loss of flesh ; night- 
sweats ; tuberculous family history ; and presence of the Bacil- 
lus tuberculosis in the sputum. L T sually terminates fatally in 
six months or three years. 

Treatment. — It is very doubtful if any remedy has ever 
cured a case of true laryngeal phthisis. What Koch's lymph 
will do remains for future investigation. (See p. 97.) In 
addition to the constitutional treatment outlined under tuber- 
culosis (p. 96), local measures are indispensable. There are 
four stages of topical treatment : 

1. Cleanse the laryngeal mucous membrane with a four-per- 



304 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

cent, solution of sodii bicarbonas or biboras with an atomizer 
or laryngeal tube. 

2. Apply a three or four grain solution of cocaiuse hydro- 
chloras with an atomizer to allay irritation and sensitiveness. 

3. Apply, with laryngeal brush or atomizer, a solution of 
argentinitras, gr. ij, or zinci sulphas, gr. i-v. 

4. Freely cover the larynx with an insufflation of iodoform or 
aristol ; or apply iodoform and ether. 

Feed through the rectum, or through an oesophageal tube, 
when they cannot swallow nourishment. 

LARYNGISMUS STRIDULUS. 

Synonyms. — Spasm of the glottis j spasmodic croup ; laryn- 
gospasm; "kinks." 

Definition. — A sudden spasmodic contraction of the laryn- 
geal muscles, closure of the glottis, and a temporary attack 
of dyspnoea or apncea. 

Etiology. — Neurotic in origin. Hereditary ; worms ; teeth- 
ing j and all debilitating diseases. A prominent cause in older 
children is bad temper. Most common in the first and second 
years. 

Symptoms. — Begins suddenly with a cessation of breath- 
ing; blueness and cyanotic condition of the skin; superficial 
veins enlarged and stand out ; lasts from one to several min- 
utes, when the spasm relaxes • a crowing, stridulous respiration ; 
a long breath, and the child falls back exhausted, or breaks 
into violent crying or screams. No after-effects. Child soon 
resumes its play. No cough, fever, or hoarseness precede or 
follow an attack. May have spasms of the muscles of the 
arms or legs ; convulsions. Relapses are frequent, and may 
have several spells in course of a, day. 

Diagnosis. — See table, Membranous Croup. 



DISEASES OF THE LARYNX. 305 

Prognosis. — Children rarely die from it unless it be from 
convulsions. 

Treatment. — Preventive. — Avoid every possible source of ir- 
ritation. Treat all gastro-intestinal disturbances and troubles 
of teething. Insist on flannel next the skin ; good, fresh 
air • most nutritious diet ; and tonics suitable for children of 
that age. If a spasm is anticipated, give a mustard foot-bath 
and cold to the head, or a few whiffs of chloroform, ether, or 
nitrite of amyl. Full doses of the bromides and chloral pre- 
vent attacks or recurrence. 

Paroxysm. — This is usually over by the time the physician 
arrives. At once immerse the body to the neck in hot water, 
and apply cold to the head. A few whiffs of an anaesthetic 
will relax the spasm, if respiration is not absolutely checked. 
Follow at once with the bromides and chloral. Lac asafoet- 
idae, gtt. v-x, or musk, gr. J, every two hours, prevents re- 
currence. 

In older children, " kinks " come from anger, and the most 
effectual cures consist in the administration of such harsh 
measures as a sound spanking, or douching the bead with a 
bucket of cold water. Medication is rarely required. 

CATARRHAL CROUP. 

Synonyms. — Spasmodic croup; false croup; "child-crow- 
ing." 

Definition. — A catarrhal inflammation of the laryngeal 
mucous membrane, without any false membrane ; accom- 
panied by spasmodic contraction of the laryngeal muscles, 
causing threatened suffocation. 

Etiology. — Occurs during the first three years of life, but 
may come later • hereditary j exposure to cold ; enlarged ton- 
sils • acute laryngitis. 



306 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Symptoms. — Prodromal. — Child is usually restless; un- 
easy ; feverish ; has a slight cough ; breathes rather heavily, 
with a harsh sound. All symptoms may be absent until the 
onset, which comes suddenly. 

Onset. — Child wakens from sleep with a harsh, metallic, 
ringing cough; great difficulty in breathing j head thrown 
back ; grasps at its throat j skin darkened or cyanosed ; super- 
ficial veins prominent; noisy, harsh breathing, or peculiar 
crowing inspiration. Symptoms gradually pass away, and 
child falls to sleep. Next day there is a slight cough. Par- 
oxysm will probably return next night or even during the 
same night. The analogy between true and false croup is so 
close that the latter may run into the former. 

Pathology. — Same as acute laryngitis, with the addition 
of spasmodic contraction of the laryngeal muscles. Not fully 
understood. 

Diagnosis. — See table, Membranous Croup. 

Prognosis. — Favorable. Death is rare. May be compli- 
cated by bronchitis or pneumonia. 

Treatment. — Prophylactic. — Exposure, the most common 
cause, must be avoided ; wear flannel next the skin the year 
round ; attend to every possible cause, and never allow any 
catarrhal trouble to be overlooked or remain untreated. 
Small doses of antimonii et potassii tart., or syr. ipecacuanhas 
with potassii bromidum, every two to four hours, often 
abort. Stimulate the emunctories. A tonic, abortive treat- 
ment is pursued by some, and consists in the administration 
of qiiininw bisulphas, gr. ij, every hour, until cough and symp- 
toms subside. 

Paroxysm. — A few inhalations of chloroform, iodide of 
ethyl, or amyl nitrite will relax spasmodic contraction of the 
laryngeal muscles. A hot bath, with cold compresses to the 
throat. Emetics of syr. ipecacuanha?, apomorphine, alum, 



DISEASES OF THE LARYNX. 307 

and mustard are recommended, but must be cautiously used 
on account of their depressing effects. Inhalations of medi- 
cated steam. Follow with tonic treatment. 



MEMBRANOUS CROUP. 

Synonyms. — Croupous, membranous, or pseudo-membra- 
nous laryngitis ; true croup ; laryngeal diphtheria. 

Definition. — An acute, specific inflammation of the laryn- 
geal and superior tracheal mucous membranes, accompanied 
by a fibro-plastic exudation or false membrane ; constant 
fever; great dyspnoea; and usually terminating in death. 

Etiology. — A disease of childhood between the second and 
seventh years. The great similarity between true membra- 
nous croup and diphtheria, and the fact that the former is 
most common during epidemics of the latter, have led some 
authors to claim that it is due to a specific microbe similar 
to or identical with that of diphtheria. Predisposing causes 
are improper hygiene, exposure to cold, debility, heredity; 
contagion doubtful. 

Symptoms. — Gradual in onset. Child is cross, fretful, 
slightly feverish; has a hoarse cough; anorexia; disturbed 
sleep; and thirst. Cough becomes ringing; attacks of dysp- 
noea; voice husky; stridulous breathing; fever increased; 
tongue coated ; white spots on the tonsils or fauces. Parox- 
ysms of marked dyspnoea, followed by a period of calm and 
repose. On the second or third day, dyspnoea is marked and 
the least excitement causes frequent severe paroxysms ; cya- 
nosis. Child grasps its throat ; head is thrown back ; retrac- 
tion of epigastrium • pieces of membrane may be coughed or 
vomited ; pulse weak ; eyes sunken and staring ; cold extremi- 
ties ; gradual coma ; and death from asphyxia, carbonic-acid 



308 



A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



poisoning, complications of pneumonia or bronchitis, on the 
sixth or seventh day. 

Favorable cases are indicated by a gradual amelioration of 
symptoms ; coughing up pieces of the membrane ; gradual re- 
turn of voice ; lessening of fever j and slow convalescence. 
Usually followed by bronchitis and temporary paralysis of 
the vocal cords. 

Pathology. — An irritant, possibly a germ, causes conges- 
tion of the laryngeal and superior tracheal mucous mem- 
branes j transudation of serum ; proliferation of cells ; and 
diapedesis of leucocytes, which gradually elongate and form 
fibrous cells and tissue known as false membrane. This 
covers and occludes the larynx and superior part of the 
trachea, and at times extends to the bronchi. When re- 
moved, small bleeding points are left. Parts are swollen and 
red. Lungs often present a condition of pneumonia, emphy- 
sema, or bronchitis, from the cupping-glass action exerted by 
forced efforts at inspiration. Kidney, liver, spleen, and 
brain are congested. Blood is thick and dark in color. 

Diagnosis. 



Laryngismus Stridu- 
lus. 

First and second years. 

Sudden onset at night ; 
no prodromes. 

Duration, a few min- 
utes. 

No fever. 

No expectoration. 



Croupal breathing 
attack. 

Usually no sequel. 



Death rare. 



m 



Catarrhal Croup. 

Second or third year. 
Sudden onset at night ; 
catarrhal prodromes. 
One to three days. 

Slight fever in attack. 
Mucous expectoration. 

Croupal breathing in 
attack. 

Slight bronchitis. 
Death rare. 



Membranous Croup. 

Second to seventh year. 

Onset gradual ; long pro- 
dromes. 

Duration, four to six 
days. 

Constant high fever. 

Expectoration of false 
membrane. 

Constantly increasing 
croupal breathing. 

Bronchitis ; pneumonia ; 
emphysema. 

Most cases die. 



DISEASES OF THE LARYNX. 309 

Prognosis. — Few cases of true membranous croup recover. 
Catarrhal or false croup is too often mistaken for true croup j 
hence the unreliability of data at our command. 

Treatment. — Whether the disease be of diphtheritic origin 
or not, the accepted treatment for either answers, and is the 
same as that used in the other. 

Onset. — Put the child in bed between blankets ; insist on 
absolute quietness ; keep the room at a uniform temperature 
and the air constantly moist with steam. Quininae bisulphas, 
gr. ij, every two or three hours, with hydrargyri chloridum 
corrosivum, gr. ■£$ to A (some prefer the use of hydrargyri 
chloridum mite). Inhalations of medicated steam (oleum 
eucalyptol and tr. iodini comp.) every few minutes or contin- 
uously; constant hot or cold compresses to the throat. If 
paroxysms are frequent and child very restless, small doses of 
pulvis opii or pulvis opii et ipecacuanhas during the first stage 
only. Full doses of pilocarpine are said to abort, but suffi- 
cient statistics cannot be obtained to speak positively. 

Second Stage. — Continue inhalations of steam ; administer 
quininas and hydrargyrum. Solvents for the false membrane 
are of little value. Sprays of lactic acid, peroxide of hy- 
drogen, and sodii bicarbonas are recommended. Better still, 
use a spray of the free chlorine mixture ; or potassii chloras, 
myrrha, and acidum carbolicum (see Pharyngitis). Failing 
in this, tracheotomy or intubation becomes necessary. See 
that the tube is always kept clear, and accomplish this by 
a small brush or feather. Sustain strength by most nutri- 
tious diet and tonics. Aconite, aqua calcis, bromides, and 
emetics are all too depressing and of doubtful utility. Emet- 
ics, remedies which have been greatly abused, have their 
place, but why use them on every occasion ? They only sap 
the little patients of that much strength and vitality that 
will be needed to tide them over the later stages. Only when 



310 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

there is a large mass of flapping, loose membrane is one 
justified in giving an emetic, and even then its utility is 
doubtful. 

Third Stage. — When recovery is imminent, the patient must 
be sustained and supported by tonics and best diet. Always 
watch the condition of the heart and let it be the guide ; re- 
move intubation-tube as soon as it can safely be dispensed 
with ; prevent exposure j treat all complications and sequelae. 



DISEASES OF THE BRONCHIAL TUBES 
AND LUNGS. 

BRONCHITIS. 

Definition. — An inflammation of the bronchial mucous 
membrane, accompanied by fever ; cough ; substernal tender- 
ness, or pain and oppression. 

Varieties. — Acute bronchitis ; plastic bronchitis ; chronic 
bronchitis. 

(1) ACUTE BRONCHITIS. 

Synonyms. — Acute catarrhal bronchitis ; cold on the chest ; 
acute bronchial catarrh. 

Definition. — An acute inflammation of the mucous mem- 
brane of the larger bronchial tubes, not attended with a 
plastic exudation. 

Etiology. — Exposure to cold, irritating dust, or vapors; 
predisposition. Most common in children. Symptomatic of 
measles and typhoid fever. 

Symptoms. — Onset is sudden, with a chill, fever, quick 
pulse, and general malaise ; or gradual, with nasal and pha- 
ryngeal catarrh, coated tongue, headache, constipation, and 
slight cough. At first the cough is dry, harsh, and paroxys- 
mal; slight expectoration of mucus, streaked with blood at 
times. Pain behind the sternum, increased by coughing or 
deep inspiration. Cough soon changes to a loose, free, muco- 
purulent or greenish expectoration, with no blood ; fever sub- 

311 



312 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

sides; percussion note usually normal; harsh, vesiculobron- 
chial breathing; sibilant or sonorous rales in first stage; 
moist and bubbling rales in second stage. 

Pathology. — Hyperasmia of mucous membrane of larger 
bronchial tubes, due to an irritant ; membrane is red, swollen, 
and dry ; vessels congested ; diapedesis and cell-proliferation. 
Secretion gradually increases, at first mucous, then muco-puru- 
lent, with desquamation of epithelial cells and, at times, rupt- 
ure of capillaries. Bronchial glands enlarged, especially in 
the symptomatic form. 

Prognosis. — Terminates favorably, and is not serious un- 
less complicated by capillary bronchitis or pneumonia. 

Treatment. — Abortive. — Quinina, and aconite or veratrum 
viride, in full doses every hour, until physiological effects are 
obtained. Acetanilide, phenacetin, and the other coal-tar 
series, are recommended by some, but are very depressing to 
the heart. Pulvis ipecacuanhas et opii, gr. x-xv, or ex- 
tractum jaborandi fluidum, gtt. xx-xl ; hot mustard foot-bath ; 
rest in bed and free diaphoresis. Hot drinks favor dia- 
phoresis. During the first stage, when the cough is dry and 
irritating, and some fever, the following is very good : 

Antimonii et potassii tart gr. j. 

Tr. aconiti vel tr. veratri f 3 ss. 

Potassii bromidi (morphinae sulph., gr. j) . . . . 3 ijss. 

Liquoris ammonii acetatis f I ijss. . 

Syr. aurantii floratis q. s. ad. f I iv. 

M. Signa. One teaspoonful every two or three hours. For 
an adult. 

Syr. seillae, syr. ipecacuanha?, liquor potassii citratis, are all 
good. It is always well to precede all medication with a 
free purge of hydrargyri chloridum mite. Inhalations of 



DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 313 

moist steam ; light, nutritious diet ; and limit the amount of 
fluids taken. 

Locally. — Mustard ; hot liniments ; poultices ; blisters 3 or 
soft, raw cotton to the chest in severe cases. 

Second stage indicates stimulating expectorants, and none is 
better than ammonii chloridum, gr. iii-x, in mistura glycyr- 
rhizae comp., every three or four hours. May be necessary to 
use cod-liver oil and stimulants in cachectic persons. Glyce- 
ritum hypophosphitum comp., f 3 j, every four hours, is good. 



(2) PLASTIC BRONCHITIS. 

Synonyms. — Membranous bronchitis ; croupous bronchitis ; 
diphtheroid bronchitis. 

Description. — An acute inflammation of the bronchial mu- 
cous membrane, accompanied by a fibro-plastic exudation, 
forming a distinct membranous cast of the large and small 
tubes. Symptoms are identical with acute catarrhal bron- 
chitis, with the addition of marked dyspnoea ; violent parox- 
ysms of coughing j and expectoration of distinct membranous 
casts of the tubes, not unlike small pieces of vermicelli. 

Pathology. — Similar to acute catarrhal bronchitis, except 
that the exudation, diapedesis, and proliferation of cells are of 
a fibro-plastic character, and probably depend upon a distinct 
germ analogous to or identical with that of membranous 
croup and diphtheria. 

Prognosis. — Usually fatal in young children; healthy, 
strong adults recover. 

Treatment — Follow the same line of treatment indicated 
in acute catarrhal bronchitis. Administer hydrargyri chlo- 
ridum corros., gr. -gV, every three or four hours ; watch the 
heart • stimulate freely in late stages ; best nourishing, easily 



314 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

digested food ; free inhalations of medicated steam. Emetics 
are nsnally of little value and too depressing. 

(3) CHRONIC BRONCHITIS. 

Synonyms. — Chronic bronchial catarrh ; " winter cough." 

Definition. — A chronic inflammation of the mucous mem- 
brane of the larger bronchial tubes, recognized b}^ the pres- 
ence of a slight cough, more severe in winter (sometimes ab- 
sent in summer) ; expectoration, slight or profuse ; slight 
bronchial rales ; no fever ; and presenting itself in the form of 
a dry catarrh ; moist catarrh ; fetid catarrh or bronchorrhoea. 

Etiology. — May be primary or secondary. Due to cold, 
exposure, great changes of temperature, all irritating vapors 
and dust, repeated acute attacks, extension from other parts, 
gout, rheumatism, tubercular and other diatheses, syphilis, 
alcoholism, heart-diseases. Also symptomatic and a sequela 
of certain fevers. Common in the aged or in children. 

Symptoms. — General. — Chronic bronchitis of all varieties 
is accompanied by a cough that manifests itself more particu- 
larly during the damp, cold months of the year, and in mild, 
early cases disappears in summer. Cough worst in the morn- 
ing and at night ; fever always absent ; loss of flesh, slight and 
scarcely perceptible at first ; acute attacks common. Percus- 
sion sounds clear, unless emphysema complicates. Ausculta- 
tion reveals all kinds of rales, depending on the variety. (See 
Auscultation, p. 292.) 

Dry catarrh (bronchitis sicca) has little or no secretion ; 
a harsh, violent, unsatisfactory, paroxysmal cough; small 
globules of tough mucus expectorated occasionally; dysp- 
noea; and substernal pain or soreness. Emphysema usually 
present. 

Moist Catarrh. — Paroxysmal cough ; expectoration of frothy 



DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 315 

mucus, muco-purulent, white, yellow, or green in tinge ; most 
annoying at night and in the morning during winter months. 

Fetid Catarrh. — Expectoration very offensive ; breath bad ; 
and always associated with bronchial dilatation. 

Bronchorrhcea. — Expectoration thin, ropy, or thick; con- 
tains little air; often fetid; may expectorate five pints in 
twenty-four hours. Common in old persons with bronchial 
dilatation. 

Complications. — Emphysema ; bronchial dilatation ; heart- 
disease ; or phthisis. 

Pathology. — Same as acute bronchitis, except that the 
course is slower. Mucous membrane gray, thickened, and in- 
filtrated. Emphysema is due to over-distention and sprain of 
the alveoli in coughing. Bronchial dilatation (bronchiectasis) 
comes from a loss of tone to the bronchial muscular fibers, 
from continued inflammation. Fetid sputum is caused by de- 
composition in the dilated bronchi before it can be expelled. 

Diagnosis. — See table, page 95. 

Prognosis. — Good, when taken early in its course. Old 
cases promise little as to cure, but are liable to be carried off 
by some complication or intercurrent affection. Predisposi- 
tion to return, to acute attacks, and to phthisis. 

Treatment — Hygienic and Climatic. — Patient should live in 
a high, dry, uniform climate (providing heart-disease is ab- 
sent) of uniform temperature, and avoid all exposure both to 
damp and cold. Light flannel must be worn next the skin ; 
personal cleanliness : nutritious diet ; pure, sweet cream and 
nitrogenous foods ; and plenty of out-door exercise, within the 
limit of endurance. Living in the balmy air of pine-forests 
of New Jersey and the Southern States, or the high, dry 
climate of Colorado, New Mexico, and Arizona, is conducive 
to rapid recovery. Regular, systematic hours for sleep, exer- 
cise, and duty, combined with good hygienic measures and an 



316 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

out-door life, will accomplish better results than medicines 
given on the " shot-gun principle." 

Medicinal Treatment. — The list of drugs recommended is 
legion, and we must be guided solely by symptoms and con- 
ditions. Pure cod-liver oil, with the phosphates or malt ex- 
tract, given continually for months, seems to give the best re- 
sults. Ammonii chloridum, administered in mistura glycyr- 
rhizae comp., is indicated in mucous or moist catarrh. Ext. 
cocillanae fluidum gives admirable results. For broncliorrJioea, 
calcis lactophosphatum, creosote, iodum, terebene, or one of 
the balsams. Never give opium for cough unless absolutely nec- 
essary. Codeina or pulv. ipecacuanha? et opii in small doses. 
Dyspnoea indicates spasmodic element — potassii iodidum, 
gr. iii-v, ter die, or physostigmina, gr. T ^o? ter die. Inhala- 
tions of steam are sometimes beneficial. Dry cupping and 
counter-irritation when indicated. Carbolic acid and iodum 
in fetid bronchitis. Watch the strength of the patient, and 
administer tonics as indicated. Avoid heart-depressants. 
Treat all complications, diatheses, and other diseased condi- 
tions present. 

CATARRHAL PNEUMONIA. 

Symptoms. — Suffocative catarrh ; lobular pneumonia ; bron- 
cho-pneumonia ; broncho-alveolar catarrh ; the so-called " cap- 
illary bronchitis." 

Definition. — An acute inflammation of the mucous lining 
of the smallest or capillary bronchial tubes and alveolar struct- 
ure, involving diffused areas in one or both lungs. 

Etiology. — Exposure to cold or dampness ; extension from 
bronchitis. Sequel and complication of influenza, diphtheria, 
measles, and whooping-cough. Predisposing causes are scrof- 
ulous and rachitic diatheses; debility; age (young children 



DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 317 

and old persons most commonly affected) ; emphysema ; heart- 
disease. 

Symptoms. — Before the capillary bronchioles and alveoli 
are invaded, the symptoms are those of an acute bronchitis. 

Onset is heralded by a rise of temperature from 102° to 
104° F. j respiration labored, increased, and difficult ; expira- 
tion prolonged and noisy ; inspiration short ; dyspnoea grad- 
ually increases and is paroxysmal ; skin dark and livid ; ve- 
nous congestion j cold perspiration ; stupor. Cough, during 
the early stages, is troublesome and rather unsatisfactory; 
later, when cyanosis begins, it lessens. Expectoration is 
scanty, muco-purulent, often in small plugs, and is sometimes 
streaked with blood. Depression marked, and a main feat- 
ure of the disease. 

Auscultation. — Vesiculobronchial breathing, with subcrepi- 
tant rales, gradually lost until resolution begins, when they 
assume a harsh and bubbling character as in bronchitis. 

Percussion. — Small areas of diffused dullness, with inter- 
vening clear areas. 

Convalescence is slow and long; weakness and depression 
marked. Death due to cyanosis, and is painless. 

Complications. — Pneumonia, tuberculosis, emphysema, ate- 
lectasis, chronic pneumonia, bronchiectasis. 

Pathology. — It is very doubtful if capillary bronchitis can 
exist alone clinically. Any inflammation of the capillary 
tubes necessarily spreads by continuity of structure to the 
pulmonary alveoli, giving rise to a condition of catarrhal 
pneumonia. The symptomatology, prognosis, sequela, and 
treatment of a theoretical case of capillary bronchitis or ca- 
tarrhal pneumonia are so closely allied that most authorities 
wrongly describe them under separate heads, on the principle 
of a theoretical difference without a clinical distinction. 

The bronchial and alveolar mucous membrane is hyperaemic 



318 A SYNOPSIS OP THE PRACTICE OP MEDICINE. 

and swollen ; new cells are proliferated ; an exudation of tena- 
cious mncns and a purulent secretion that block the air-cells 
and bronchioles and act as a valve, causing imperfect aera- 
tion of the blood, cyanosis, functional atelectasis, emphy- 
sema, slight consolidation, and dullness. Resolution causes 
fatty degeneration, absorption and expectoration of the exu- 
dation, and hyperplasia. 

Diagnosis. — Pneumonia is self -limited • ends by crisis ; has 
rusty or bloody sputum ; unilateral and circumscribed. 

Acute Bronchitis. — Little or no fever ; no dyspnoea ; no dull- 
ness on percussion; large, moist, and bubbling rales; no 
marked prostration. 

Prognosis. — Occurring as it does in debilitated children 
and old persons, is usually fatal in fifty percent, of the cases. 
The mortality is much less in middle age and hardy persons. 
Convalescence is long and tedious. Ends oy lysis. Acute stage 
lasts about two weeks. The great danger lies in weakness 
and complications. 

Treatment. — Confine patient to bed in a room with a uni- 
form temperature. Avoid every source of cold and excite- 
ment. If seen in its incipient stage, administer full doses of 
tr. aconiti, tr. veratri, vinum autimonii, or liq. ammonii 
acetatis. Apply strong counter-irritation over the chest. Hot 
drinks and free diaphoresis. Quinina in small, tonic doses. 
When the disease is pronounced or fully developed, all de- 
pressants must be avoided, and alcoholic stimulants should 
be freely used. The chest should be rubbed with turpentine, 
camphor, or croton-oil and incased with raw cotton. Free, 
hot inunctions of cod-liver oil or sweet-oil, night and morn- 
ing. The coal-oil products, although freely used by some, 
are entirely too depressing in their action, and should be used 
only with great caution. 

Cough. — Never give opium, as it counteracts the very means 



DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 319 

nature has provided for clearing away accumulations of 
mucus. Inhalations of medicated steam are sometimes benefi- 
cial, but possess the evil effects of relaxing the tissues. Small 
doses of any stimulating or sedative expectorant every two 
or three hours — ammonii carbonas ; syr. ipecacuanhas ; min- 
eral acids. Emetics of apomorphine and sulphate of zinc are 
said to relieve impending suffocation, but are extremely de- 
pressing, and must be used only as a last resort. 

Convalescence. — Best nitrogenous diet ; cod-liver oil ; change 
of climate to sea-shore or mountains, for several months, if 
possible. Live constantly in the open air and exercise mod- 
erately. 

HEMOPTYSIS. 

Definition. — Haemoptysis, a symptom of disease, is a term 
applied to hemorrhage from the broncho-pulmonary tract. 

Etiology. — Tubercular ulceration is a common cause ; ob- 
structive and valvular heart-troubles ; pulmonary hyperaemia ; 
excessive spraining or coughing ; inflammation ; hemorrhagic 
diathesis; anaemia; breaking of a pulmonary aneurysm; gan- 
grene ; cancer ; vicarious menstruation ; idiosyncrasy ; plethora. 

Symptoms. — Symptoms of causative disease. A feeling 
of fullness, burning, or tickling in the throat or behind the 
sternum, followed by a salty taste in the mouth and expecto- 
ration of frothy or pure alkaline blood. Sometimes patient 
has a salty taste in the mouth for days before hemorrhage 
takes place. It either follows severe coughing or may come 
suddenly without symptoms. Blood may be coughed up or 
flow without coughing. Patient becomes excited ; pulse quick 
and tense ; skin pale and covered with cold sweat. Hemor- 
rhages apt to recur at intervals of a few days or months. 
Bubbling rales on auscultation and localized dullness on per- 
cussion. Small particles or casts of dark blood are coughed 



320 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

up for several days or weeks after hemorrhage. Pathology 
and prognosis depend on causative affection. Patients rarely 
die from hemorrhage, unless due to breaking of a pulmonary 
aneurysm. 

Diagnosis. — See page 208. 

Treatment. — Preventive. — Treat cause. Establish menstru- 
ation when it is vicarious. In plethora, relieve by regulating 
diet and venesection. Foresee the probability of hcemoptysis in 
iveak, scrofulous children, and strengthen them. Thickness of 
the blood tends to avert hemorrhage ; hence regulate fluidity 
by diet, hydragogues, and salines. In anaemia, give iron. 
Ten grains of calcis lactophosphatum, dissolved in a glass of 
water, and sipped during the day, will tone the bronchial mu- 
cous membrane and vessels. When there is a feeling of full- 
ness behind the sternum, as if a hemorrhage were imminent, 
twenty drops of tr. digitalis in hot water, every four hours, 
accompanied by a small blister, and reassurance of the pa- 
tient, with rest in bed, often prove effective. 

During the hemorrhage, apply ice to the chest ; administer a 
hypodermic of morphince sulphas, gr. \ ; absolute rest in bed in 
recumbent position. If heart is tumultuous and strong, give 
aconite, veratrum, or gelsemium. The condition of the heart 
indicates the use of stimulants or depressants. Small pieces of 
ice or common salt in the mouth constitute remedies used by 
the laity. Hypodermics of ergot are of little avail, as they do 
not contract the pulmonary arterioles as expected, and may 
do more harm than good. Hemostatics in general are of little 
avail, as the hemorrhage is over by the time they begin to 
act. Inhalations and sprays during the hemorrhage are absolute- 
ly worthless, as they never reach the lung structure or seat 
of hemorrhage. Strictly avoid all hot drinks, coughing, talk- 
ing, and excitement. 

Convalescence. — Rest in bed; flying blisters on chest; moist 



DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 321 

air; uniform temperature; morphina or codeina to control 
coughing. Phenacetin or acetanilide for fever. Quinina 
alone favors hemorrhage. Diet of milk, rice, beef -juice, 
white of egg, and a little acidulated drink. Gradually harden 
patient, and insist on change of climate by a long sea- voyage ; 
mountain life, and out-doors most of the time. 



PULMONARY HYPEREMIA. 

Synonyms. — Congestion of the lungs; active or passive 
fluxion of the lungs. 

Definition. — A congestion of a portion of one or both 
lungs. 

Etiology. — Active Hypercemia. — Violent heart-action ; over- 
stimulation ; violent exercise ; alcoholism ; direct irritation ; 
excitement. 

Passive Hypercemia. — Valvular heart-diseases ; dilatation or 
hypertrophy of the heart ; obstruction of pulmonar}^ circula- 
tion by tumors, thrombi, emphysema, or pneumonia. Feeble 
heart-action. Complicates fevers and Bright's disease. 

Symptoms. — A sense of fullness, without pain, over the 
chest ; short, dry, hacking cough, with an occasional expec- 
toration of frothy or bloody mucus; dyspnoea of varying 
character ; no fever ; pulse strong and full ; lasts two to seven 
days. Chronic hypercemia presents similar symptoms, not so 
acute at first. Slight impairment of resonance on percussion ; 
diminished vesicular murmur, with moist and subcrepitant 
rales. 

Pulmonary (Edema. — Acute or chronic hyperemia is fre- 
quently followed or accompanied by an exudation of serum 
into the pulmonary alveoli, causing marked dyspnoea ; cyano- 
sis ; serus or tough mucus expectoration, tinged with blood ; 



322 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

large, moist rales ; slight impairment of resonance on percus- 
sion. 

Pathology.— Lnngs dark red, and do not wholly collapse ; 
capillary vessels distended with blood. Section resembles 
splenic structure j hence the term splenification. When serum 
has exuded into alveoli (oedema), the lung pits on pressure j is 
heavy • does not collapse 5 serum and blood escape on section. 

Prognosis. — Always grave, unless active treatment is em- 
ployed; depends on cause. Simple acute cases terminate in 
two to seven days. (Edema is always attended with doubt. 

Treatment. — Strike directly at cause. When pulse is full 
or death imminent, venesection at once. Dry or wet cups. 
Free purgation ; diaphoresis. Stimulants as indicated. Emet- 
ics often relieve. Passive congestion demands regulation of 
cause. Avoid large quantities of hot drinks or hot foods, hot 
or cold air, and all excitement. Milk diet ; free use of fruits 
and acids. Mild cases are averted by aconite or veratrum. 

Tr. veratri viridis vel tr. aconiti rad gtt. j. 

Vini antimonii gtt. iv. 

Tr. opii gtt. j. 

Liq. ammonii acetatis f 3 ss. 

M. Signa. Every hour, in water, until relieved. 



APNEUMATOSIS. 

Definition. — Collapse of the air-cells in certain portions of 
the lungs, either acquired or congenital. A symptom, not a. 
disease. 

Varieties. — Congenital apneumatosis or atelectasis; ac- 
quired apneumatosis. 

Etiology. — Congenital. — Improper expansion of air-cells at 



DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 323 

birth on account of weakness ; improper innervation or 
bronchial obstruction. 

Acquired. — Blocking of bronchial tubes by mucus or foreign 
bodies ; bronchitis ; laryngeal or tracheal obstruction ; pneu- 
monia ; compression by pleural effusion ; pericardial effusion ; 
tumors ; cancer ; aneurysm ; and spinal curvature. 

Symptoms. — Patient is weak; skin and nails livid from 
improper aeration of blood ; speaks in low voice or whispers ; 
respiration shallow and hurried ; pulse feeble ; absence of 
vesicular murmur over affected area ; slight dullness, on per- 
cussion, recognized at bases of lungs. Temperature often 
subnormal. 

Congenital apneumatosis shows itself, at birth, in weak chil- 
dren who cry very little ; abdomen retracted ; skin bluish ; in- 
tercostal spaces sunken ; great difficulty in nursing. Acquired 
apneumatosis, recognized by symptoms of cause as well as 
those mentioned. 

Pathology. — Lung dense; heavy; sinks in water ; contains 
no air in affected area. Most common in lower lobes of lung. 
Acquired cases of compression are bloodless, airless, and a 
gray or reddish-brown color (carnification). A bronchus be- 
comes blocked ; incloses air in the alveoli, which is absorbed ; 
alveolar walls collapse and contract. The "valvular action n 
theory is hardly probable. 

Treatment. — Congenital. — At birth, see that the child cries 
long and hard to completely fill the air-cells. Throw hot 
water in its face ; strike its chest with a cold towel to induce 
respiration. Artificial respiration if necessary. Stimulate 
freely, and avoid exposure. 

Acquired. — Seek cause and remove if possible ; inhalations 
of compressed air and oxygen ; daily pulmonary gymnastics ; 
supporting and stimulating diet. Stimulating expectorants 
if indicated. Symptomatic treatment. 



324 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



VESICULAR EMPHYSEMA. 

Definition. — A condition of the king in which the air-vesi- 
cles are enlarged ; the tonicity or continuity of their walls de- 
stroyed; and an escape of air into the connective and sub- 
plenral tissue. 

Etiology. — Forced or prolonged inspiration or expiration, 
as in coughing or blowing wind-instruments; lack of nu- 
trition and degenerative changes of alveolar walls ; heredity. 
Follows pneumonia, chronic bronchitis, asthma, whooping- 
cough, and over- exertion. Compensatory emphysema in 
phthisis. Present in young adults and old persons. 

Symptoms. — Begins with shortness of breath and symp- 
toms of bronchitis. Least exertion causes marked dyspnoea ; 
cold air and asthma aggravate it ; dyspnoea increases, and is 
worst at night. Face is dark, livid, and veins prominent; 
nostrils dilated ; mouth open ; head thrown back ; and all mus- 
cles of respiration are used to obtain breath. 

Auscultation. — Prolonged expiration ; short inspiration ; 
vesicular murmur diminished; whistling, moist, or bubbling 
rales ; vocal fremitus diminished ; heart-sounds displaced. 

Percussion. — Marked tympany or Iryper-resonance • cardiac 
dullness, lessened and slightly displaced; liver dullness, de- 
pressed. Chest assumes a cylindrical or so-called "barrel 
appearance v ; more or less stooping : lower part of chest con- 
tracted ; intercostal spaces widened ; and whole chest moves 
on respiration. Paroxysms of spasmodic asthma complicate. 

Pathology. — Forced dilatation of the air- vesicles causes a 
loss of tone to their walls ; these gradually atrophy or degen- 
erate from lack of nutrition, and ultimately rupture, thus 
merging a number of air-cells into one and allowing air to 
escape into the connective tissue. This causes obstruction to 
pulmonary circulation ; extra work on the right side of the 



DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 325 

heart, with hypertrophy, dilatation, fatty degeneration, and 
the train of symptoms consequent npon this condition. Left 
lung is most susceptible, and in upper lobes. Paroxysms of 
dyspnoea are due to neurotic element present. Lungs do not 
collapse on opening the chest- walls ; crackle on pressure ; con- 
tain air-spaces the size of a small cherry; do not sink in 
water ; very pale in color or light gray. 

Prognosis. — Rarely if ever causes death directly. Patients 
die of complications — bronchitis or heart-disease. 

Treatment. — Preventive.- — Prohibit forced inspiration, ex- 
piration, or any physical cause ; treat conditions of bronchitis ; 
give dry, most nutritious diet, such as meat, albumens, and con- 
centrated foods. Open-air exercise in moderation; slight 
work ; and " put off the day on which he will become an in- 
valid." Tonics of iron, quinine, and cod-liver oil. Change 
of climate. Potassii iodidum, with tonics or lobelia, relieves 
the spasmodic element and retards the disease. (Form, p. 
327.) 

During a paroxysm, administer a hypodermic of morphinse 
sulph., gr. i, and atropinae sulph., gr. T ^ ; inhalations of com- 
pressed air or oxygen. Attacks are often relieved in a half- 
hour or less by inhalations of equal parts of nitrous oxide 
and pure oxygen. Nitroglycerin or eserine, gr. too, ter die, 
relieves dyspnoea in some cases. 

BRONCHIAL ASTHMA. 

Definition. — A functional, paroxysmal neurosis of the re- 
spiratory tract, recognized by attacks of great dyspnoea, 
which are followed by intervals of repose. 

Etiology. — Exciting Causes. — Change of weather; cold 
air ; climate ; inhalation of dust, smoke, or irritating vapors 
and powdered ipecac ; pollen from flowers or grain ; over- 
eating; sexual excesses; particular articles of diet; excite- 



326 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

merit or fear ; Bright's disease ; any irritation to the pneu- 
mogastric nerve. 

Predisposing Causes. — Heredity ; bronchitis ; emphysema ; 
gouty diathesis; debility. More common in men, young 
adults, and high walks of life. 

Symptoms. — Paroxysm. — Usually appears between two and 
four o'clock a.m., or in the afternoon. Wake with a sense of 
oppression of the chest, with great effort at breathing. May 
be preceded by drowsiness, uneasiness, sneezing, and slight 
coughing. Sudden dyspnoea, rapidly increasing; gasps for 
breath ; head thrown back ; mouth open ; muscles of respira- 
tion standing out; chest full and rounded; veins full and 
prominent ; skin dusky • whistling, unsatisfactory cough ; no 
fever ; cannot lie down. Patient wants near an open window. 
Inspiration is short and wheezing; expiration prolonged and 
noisy. Hyper-resonance on percussion ; vesicular murmur ab- 
sent or weak ; sibilant, wheezing, and whistling rales. Slight 
expectoration of grayish pellets of mucus, often stained with 
blood. After a few hours, paroxysm subsides, but may last 
for days, and returns at indefinite periods. 

Pathology. — Undoubtedly of neurotic origin. Having a pre- 
disposition to asthmatic attacks, an irritant to the peripheral 
branches of the pneumogastric nerve causes contraction of 
the involuntary muscular tissue surrounding the smaller 
bronchi; narrowing or occluding their caliber; preventing 
the normal tidal respiration ; hence all the symptoms. The 
catarrhal theory of a temporary swelling of the bronchial 
mucous membrane is hardly plausible, owing to the sudden- 
ness of the onset and the ready response to treatment. When 
complicating other affections, we have in addition the pathol- 
ogy of the disease. 

Diagnosis. — Cardiac Asthma. — Not paroxysmal ; very per- 
sistent ; history of heart-disease ; general symptoms. 



DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 327 

Laryngeal affections and polypi differentiated by direct ex- 
amination, and not readily mistaken. 

Prognosis. — Never directly fated. Great danger lies in 
complications, such as heart-disease, emphysema, and dropsy. 
A chronic disease, and rarely if ever cured. 

Treatment. — Paroxysm. — Inhalations of equal parts of ni- 
trous oxide and oxygen, nitrite of amyl, ether, chloroform, or 
bromide of ethyl. Tablets of trinitrin, gr. y^o, dissolved in 
mouth. Hypodermic of morphina and atropina is very effi- 
cient, but not always desirable. Bromides and chloral. 

Nauseants of lobelia, ipecacuanha, and smoking belladonna 
and stramonium leaves, steeped in niter and dried, are com- 
mon, mild measures, but rather undesirable. Ext. grindeliae 
fluidum. Stimulants of hot coffee, strychnina, alcoholic prep- 
arations, or cocoa in nervous subjects. Phenacetin or acet- 
anilide, in ten or fifteen grain doses, may give rapid relief in 
obstinate cases where other means have failed. Inhalations 
of condensed air, with exhalation into rarefied air. Make a 
strong mental impression on patient. Fright is said to have 
cured very obstinate paroxysms. All remedies gradually fail 
in time. Sangree claims excellent results from an ice-pack. 

Preventive. — Systematic course of arsenic, alternated with 
potassii iodidum, and change of air. Avoid all causes. Treat 
complications. Light diet ; never eat a full meal. Hunt for 
and treat all possible reflex causes, such as uterine diseases in 
women. When threatened with a paroxysm, give : 

Tr. lobeliae f 3 v. 

Ammonii iodidi 3 j. 

Syr. pruni virginianae f 1 ijss. 

Aqua? q. s. ad. f 1 iv. 

M. Signa. One teaspoonf ul every two or four hours as nec- 
essary. 



328 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



PNEUMONIA. 

Synonyms. — Croupous or lobar pneumonia j pneumonitis ; 
u lung-fever." 

Definition. — An acute, localized, croupous inflammation of 
the alveolar structure of one or more lobes of the lung, ac- 
companied by an exudation into the air-cells. 

Etiology. — Recent research seems to point to a distinct 
germ {Micrococcus pneumonia?) as the cause of pneumonia. 
Exciting and predisposing causes are exposure to cold and 
dampness 5 alcoholism; rheumatism; gout; and debility of 
any kind. Surgical causes are foreign bodies ; injury to chest- 
walls by blows or penetration. Most common in winter ; not 
self-protective ; contagious ( ? ) ; at times epidemic ; middle lif e 
usually, twentieth to forty-fifth year. Recently classed as an 
acute, infectious or contagious fever. 

Symptoms. — Onset or First Stage. — Begins with an uneasy 
sensation in chest ; pain in the head and back ; tongue furred ; 
malaise ; slight cough ; chilly sensations, followed by one dis- 
tinct cMll 7 not repeated ; rise of temperature from 102° to 105° F. 
Fine subcrepitant rales on auscultation (similar to the sound 
produced bjr rolling the hair between the fingers) at end of 
inspiration, localized usually in one lobe of either lung. 
Sometimes the onset is insidious. Percussion note unaltered. 
Cough at first is dry, but changes to expectoration of sticky 
mucus, stained with blood. A dull or sharp pain over the 
region of nipple. Pulse not increased proportionately to the 
rapidity of breathing. 

Second Stage. — Respiration grows quicker and more shallow 
— from thirty to ninety per minute; pulse slightly increased; 
temperature high, 104° to 105° F. ; skin very dry and hot ; 
marked localized dullness on percussion over diseased lobe : 



DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 329 

vesicular murmur lost, aud replaced by bronchial breathing ; 
bronchophony; lessened chest movement on affected side. 
Cough painful, and expectoration is of a thick, tenacious, rusty- 
colored, or bloody character. Slight delirium. Urine acid, 
high-colored, and chlorides diminished; occasional albumi- 
nuria. Jaundice complicates, but is rare. An eruption of 
herpes often occurs on lips, anus, or limbs between second 
and fifth day. 

Third Stage. — Resolution. Between the sixth and ninth day, 
temperature, respiration, and pulse fall oy crisis. Paralysis 
of the heart (heart-failure) is most common in this stage. 
Tongue moist; skin assumes a natural condition, and all 
symptoms improve. Dullness gradually diminishes; redux 
crepitant rales. Cough not so painful ; sputum becomes yel- 
low or greenish, less sticky, and loses bloody character. 

In place of crisis and resolution, the case may run on to 
caseation, with a high evening temperature ; dullness and slow 
cough ; marked depression ; night-sweats ; and slow recovery. 
In old persons, expectoration may become red and serous — 
"prune-juice " expectoration. Many cases assume a typhoid nat- 
ure and are improperly termed typhoid pneumonia. 

Pathology. — Onset. — An irritant, probably the Micrococcus 
pneumonia?, causes a congestion of the alveolar mucous mem- 
brane of one or more lobes of the lung — most commonly the 
lower right lobe. In aged persons and in children the apex 
is most commonly affected. An exudation of thick, tenacious 
serum, which causes adherence of walls of the air- vesicles ; 
hence the fine subcrepitant rales caused by their expansion at 
end of inspiration. Lobe of lung is red or reddish brown ; is 
in a stage of congestion ; contains frothy serum, new cells, and 
proliferated epithelium ; and floats in water. 

Second Stage. — Red hepatization, or stage of exudation. Exu- 
dation into air- vesicles continues ; embryonic cells are formed ; 



330 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

epithelium is proliferated ; diapedesis ; and occlusion of air- 
cells. Lung is red 5 cuts like liver and looks not unlike it ; 
sinks in water. 

Third Stage. — Resolution or gray hepatization. Fatty de- 
generation of the exudation; absorption of part and expec- 
toration of remainder until air-cells resume their normal 
condition. Color grayish, due to leucocytes and decolorized 
red blood-cells. 

If resolution fails, there is a fourth stage, in which the lung 
is soft ; infiltrated with purulent material ; localized abscesses ; 
usually followed by death from septicaemia, pyaemia, or pul- 
monary gangrene. 

Pleuro-pneumonia is a complication of pleurisy and pneu- 
monia, and should never be used as a synonym for pneumonia, 
which is a separate affection. 

Diagnosis. — See Pleurisy, page 337. 

Prognosis. — Sthenic {active) pneumonia usually terminates 
favorably in ten days or two weeks b}^ crisis. Asthenic (inac- 
tive or lingering) cases are unfavorable. When complicating 
alcoholism or kidney affections, mostly fatal. Unfavorable 
signs are very rapid breathing, with low temperature ; marked 
delirium or convulsions ; involvement of both lungs ; abscess ; 
gangrene ; paralysis or weakness of the heart ; hyperpyrexia 5 
typhoid symptoms; and jaundice. Death may occur from 
collateral hyperaemia or oedema in the first or second week ; 
in the second stage, from cerebral engorgement, paralysis or 
weakness of the heart ; third stage, from albuminuria or sep- 
tic infection. 

Treatment. — Absolute rest in bed. If called during onset, 
when heart's action is full and bounding, give tr. aconite or 
veratrum (with or without tr. phosphorus, gtt. i-ij, every two 
hours), every hour or half -hour (form, p. 322) ; vinum anti- 
monii or liq. ammonii acetatis ; and a full saline purge, until 



DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 331 

symptoms are abated. A pill of aconitina, digitalin, and 
veratrina is very good. Many cases that threaten to become 
true pneumonia are entirely checked by this treatment. Full 
doses of acetanilide or phenacetin are so depressing that they 
must be guarded or entirely omitted. Blood-letting, an old 
method formerly practiced in most cases, has justly fallen 
into disrepute. It is only justifiable in intense congestion, 
threatened oedema, or pneumonia of alcoholism. Blood-let- 
ting drains away too much nutritive principle from the blood 
that will be needed later during crisis and convalescence. 
Wet cups ; tr. iodi ; or blisters over chest. Incase chest with 
raw cotton or poultices, kept constantly hot. Raw cotton is 
preferable, as poultices cannot be kept hot and are liable to 
chill patient during changing. Inunctions of hot oil, daily, 
to chest add to protection. 

After the stage of excitement or onset, avoid all depress- 
ants, and, from this time until crisis is past, watch the heart 
closely and stimulate with strychnina or ammonii carbonas, 
gr. ii-v, every two or four hours, combined with tonic doses 
of quininae bisulphas. Digitalis contracts the bronchial arte- 
rioles and is not desirable. Give richest, concentrated, albu- 
minous diet, so that the bulk of the blood may be kept small 
and rich. Watch closely for crisis, and be ready to administer 
a full dose of ammonii carbonas or other stimulant to avert 
fatal syncope. 

During resolution, give stimulating expectorants ; Huxom's 
tincture of bark ; glyceritum hypophosphiti comp. ; and good 
diet. Never allow patient to go out-doors until all symptoms 
of the disease have disappeared. The Germans reduce fever 
by cold baths or cold packs. The main point in treatment of 
all stages is to support the heart. Opium must be avoided 
unless absolutely indicated. 



332 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



CHRONIC PNEUMONIA. 

Synonyms. — Pneumonic phthisis; caseous pneumonia; 
scrofulous pneumonia; non-tubercular consumption. 

Definition. — A chronic inflammation of the parenchyma- 
tous structure of the lungs, accompanied by degeneration of 
lung-tissue and formation of cicatricial tissue, usually termi- 
nating in phthisis tuberculosis. 

Etiology. — Predisposing Causes. — Low vital powers ; scrofu- 
lous and tubercular diathesis ; debilitating diseases ; heart-dis- 
eases ; and chronic bronchitis. Exciting causes are bad colds ; 
pneumonia; acute bronchitis ; irritating gases ; and dust. 

Symptoms. — Following pneumonia or bronchitis, patient 
often complains of chilliness or rigors in afternoon, followed 
by rise of temperature from 102° to 104° F. ; profuse and ex- 
hausting night-sweats ; morning temperature normal. Cough 
worst in morning and night. Expectoration of frothy mucus ; 
tenacious grayish pellets, purulent or blood-streaked. Hce~ 
moptysis rare. Dullness on percussion over lower lobes of 
lungs mostly. Cavities. Mucous rales ; bronchial breathing 
and bronchophony. Loss of appetite ; great prostration ; face 
flushed in afternoon. Intermittent fever with rigors indicates 
purulent infiltration. Chest- walls sunken ; marked supra- and 
infra-clavicular depression. 

Pathology. — Although classed as a non-tubercular affec- 
tion, its origin is questionable. When caseation is present, 
the case is undoubtedly tuberculous. Inflammation spreads 
to interstitial tissue, forming new fibrous tissue, which con- 
tracts, cuts off nutrition, causes atrophy, degeneration, and, 
in many cases, purulent infection. Tissue breaks down ; is 
expectorated ; and leaves cavities. Fever is hectic in type. 
Communication may be established between the lung and 



DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 333 

pleura, causing pneumothorax. Interference with circulation 
causes dilatation of right ventricle of heart and its train of 
symptoms. 

Diagnosis. — See Chronic Tuberculosis, page 95. 

Prognosis. — When taken early, many cases are checked, 
and patients live for years, often dying of other affections. 
Untreated cases terminate fatally in three to five years. 

Treatment. — Very best hygienic surroundings; constant 
out-door life in a dry, uniform climate ; best nutritious diet ; 
sweet, rich cream ; exercise in moderation. Rest in bed dur- 
ing the afternoon hours when fever comes on. Combat fever 
with pill acetanilide comp. (form, p. 27) or other antipyretics. 
Break night-sweats with tr. belladonna?, atrophia, zinci oxidum, 
or a cup of strong, hot sage-tea, a few moments before retir- 
ing. Expectorants are indicated in chronic bronchitis. Treat 
bronchorrhoea. Calcium lactophosphate, glycerol phosphates 
comp., and cod-liver oil. Avoid hypnotics. Symptomatic 
treatment. The main feature is to prevent tubercular infec- 
tion. 

FIBROID PHTHISIS. 

Description. — A variety of chronic pneumonia that invades 
the interstitial tissue of the lung, with hyperplasia, hyper- 
trophy, and formation of contractile tissue, which contracts 
and obliterates the alveoli and bronchioles. Most common in 
those who work in mills, factories, and dust. Called miner's 
phthisis ; cirrhosis of the lung; and Corrigan's disease. Slight 
cough, worst in cold, damp months; little expectoration at 
first. As disease process advances, symptoms are identical 
with true pneumonic phthisis, and the case is liable to become 
tuberculous. Marked retraction of chest- walls from pleuritic 
adhesions. Dullness on percussion, with isolated areas of 
tympanitic resonance. 



334 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Prognosis. — Disease may be held in check for years. Aver- 
age duration is ten to fifteen years. Tuberculous infection 
is the usual ultimatum. 

Treatment. — Avoid cause by change of occupation, out- 
door life, and treat as in chronic pneumonia. Hydrargyri 
chloridum corros. ; aurii et sodii chloridum ; iodides ; and 
other alteratives or absorbents may prevent hyperplasia, but 
can never restore lost tissue. 



DISEASES OF THE PLEURA. 



ACUTE PLEURISY. 

Synonym. — Acute pleuritis. 

Definition. — Localized, or diffuse, acute inflammation of 
the serous membrane lining the pleural cavities, accompanied 
by a plastic exudation, and terminating in resolution or 
chronic pleurisy. 

Etiology. — Exposure to cold or wet ; traumatism. Second- 
ary to pneumonia ; Bright's disease of kidneys ; variola ; rheu- 
matism; phthisis; pericarditis; septic and eruptive fevers; 
pneumothorax ; and all septic poisons. 

Symptoms. — First Stage. — Dry stage, or onset. A chill or 
rigor, often repeated, accompanied by severe, sliarp pain in the 
side, near the nipple, which is increased by respiration, cough- 
ing, talking, and deep pressure in intercostal spaces. Some 
fever, ranging from 100° to 104° F. Respiration increased 
and shallow ; slight dyspnoea ; tongue coated ; constipation. 
Chest- walls do not move regularly on affected side ; pulse 
rapid. Dry, hacking cough, very much suppressed. Vesicu- 
lar murmur lessened, and replaced, over affected area, by a 
friction-sound heard during inspiration and expiration. Fric- 
tion-sound varies in degree from a very slight to a harsh, 
grating sound, which cau be recognized by placing the hand 
on chest- walls. Patient lies on affected side. 

Second Stage. — Effusion. By end of second or third day, 
friction-sounds lessen and disappear ; vocal fremitus lessened j 

335 



336 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

no vesicular murmur ; aegophony ; localized dullness on per- 
cussion, varying with position. When sitting, dullness is low 
down posteriorly. Pain decreases ; dyspnoea increases accord- 
ing to effusion. Loss of movement on affected side of chest ; 
intercostal spaces full ; very little or no cough 5 fever from 
100° to 102° F. ; prostration ; quick pulse ; heart often dis- 
placed by effusion. When there is no perceptible effusion, 
the case is termed dry pleurisy. 

Third Stage. — Resolution. In second week fever lessens; 
effusion disappears rapidly or slowly ; vesicular murmur re- 
turns ; friction-sounds ; lung gradually expands ; chest- walls 
and intercostal spaces sink slightly, or, in some cases, mark- 
edly. If case does not progress to resolution, it becomes 
chronic (q. v.). 

Pathology. — First Stage. — Hyperemia of pleural serous 
membrane, usually localized to a part or the whole of one 
pleural cavity. Vessels engorged, dilated, and membrane of 
a dull red in place of a normal shining appearance. Pain is 
caused by friction of inflamed membrane during respiratory 
efforts. 

Second Stage. — Exudation of leucocytes ; cell-proliferation 5 
and formation of a flbro-plastic, sticky exudation, which ar- 
ranges itself in layers on the membrane (dry pletu'isy), or may 
continue by an exudation of serum or a fibrinous fluid, in 
large amounts, nearly filling the pleural sac. Effusion presses 
on lung, causing temporary or permanent apneumatosis. Pain 
is lessened by intervention of effusion between inflamed folds 
of the membrane, preventing direct friction. 

Third Stage. — Effusion is gradually absorbed; folds of 
membrane come in contact and form adhesions of fibrous 
tissue. 



DISEASES OF THE PLEURA. 



337 



Diagnosis. 



Acute Pleurisy. 



Onset by several chills or rigors. 
Friction-sound during inspiration 
and expiration. 

Moderate febrile symptoms. 
Short, dry cough. 
Pain sharp and shooting. 
Dullness changing with position. 
Absence of vesicular murmur and 
fremitus. 

Chest enlarged ; intercostal spaces 
bulging. 

Frothy expectoration. 

Terminates by lysis. 

No bacillus demonstrable. 



Pneumonia. 



Onset : one distinct chill. 

Subcrepitant rale at end of inspira- 
tion. 

Marked febrile reaction. 

Cough with expectoration. 

Dull pains. 

Dullness localized ; unchanging. 

Fremitus increased. 

Absence of chest-enlargement. 

Bloody or " rusty " expectoration. 
Terminates by crisis. 
Micrococcus pneumoniae. 



Intercostal neuralgia and myalgia are distinguished by being 
paroxysmal ; location ; absence of physical signs ; and differ- 
ence in onset. 

Prognosis. — Most cases recover in three or four weeks by 
resolution. Many become chronic. Complicated by pneu- 
monia or empyema. Secondary pleurisy offers a bad prognosis. 

Treatment. — Onset. — If pain be very severe, dyspnoea great, 
and pulse full, administer a hypodermic injection of morphina 
and atrophia. Give tr. aconiti or tr. veratri every hour (form, 
p. 322), until heart's action lessens. In plethoric, full-blooded 
persons with a full, bounding pulse, venesection is justifiable 
and gives quick relief. Leeches, dry cups, or blisters; hot 
applications, provided they be kept hot constantly, relieve 
pain, when not too severe. If heart be weak, infusion of 
digitalis, administered in hot water. Full doses of phena- 
cetin, acetanilide, or salicylates lessen full pulse and fever, 
but are too depressing. A full dose of tr. jaborandi, to pro- 
duce free diaphoresis, is said to abort many threatened 



338 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

cases. Strapping the affected side with adhesive straps will 
lessen chest-movements and relieve pain. Opium must be 
avoided as much as possible. (See Peritonitis.) Inhalatious 
of oxygen. 

Effusion. — Great effusion, with marked dyspnoea, requires 
immediate aspiration, with perfect antiseptic precautions. 
Infusion of digitalis with potassii acetas or nitras, every two 
to four hours, often lessens it, if combined with free saline 
laxatives and use of minimum amount of liquids. 

Resolution, — Diaphoresis, diuresis, and salines to favor ab- 
sorption of lymph. Potassii iodidum or syr. ferri iodidi aids 
in absorption of lymph. Most nutritious diet; iron tonics 
and stimulants as indicated. 



CHRONIC PLEURISY. 

Synonym. — Chronic pleuritis. 

Definition. — A chronic inflammation of the serous lining- 
membrane of the pleural cavities, recognized by a history of 
acute or subacute pleurisy; presence of pleuritic effusion; 
absence of acute symptoms ; and gradual loss of flesh. 

Etiology. — Most commonly follows acute or subacute pleu- 
risy. Complicates tuberculosis ; pneumonia ; Bright's disease ; 
sy philis ; rheumatism ; or alcoholic excesses. 

Symptoms. — Usually latent and not constant ; no marked 
dyspnoea ; slight or no cough ; may have marked emaciation, 
or no loss of flesh. At times there is hectic fever, night- 
sweats, and rapid pulse. Respiratory and voice sounds ab- 
sent or diminished; dullness on percussion, varying with 
position, if general ; or dullness constant, if sacculated ; chest 
full ; intercostal spaces bulging and wide ; diminished motion 
on affected side during respiration; heart and liver displaced. 



DISEASES OF THE PLEURA. 339 

No pain. When absorption occnrs, chest- walls sink ; feeble 
breath and king sounds. Effusion in chronic pleurisy often 
becomes infected with pyogenic germs and produces empyema, 
with marked hectic fever, chills, and emaciation. May point 
as an abscess in intercostal spaces ; break ; allow pus to escape 
and air to euter pleural cavity, causing pneumothorax. Ab- 
scess may open into lungs and be expectorated; perforate 
diaphragm or pericardium. 

Pathology — Same as in acute pleurisy, but much slower 
and more chronic. Membrane thick ; dull-gray color ; very 
rough; and many bands of adhesion. When infected with 
pyogenic germs, the whole mass becomes purulent (empyema). 

Diagnosis. — Hydrothorax is bilateral; complicates kidney 
and cardiac diseases, with no inflammatory history. Aspirator 
is best diagnostic agent. 

Prognosis. — Chronic pleurisy may last for years without 
endangering life. Great danger lies in empyema or tuber- 
cular infection, both of which are dangerous to life — the latter 
always fatal in time. 

Treatment. — Chronic pleuritic effusion requires dry, nutri- 
tious diet ; saline cathartics ; minimum of liquids ; and flying 
blisters to chest. Aspiration often proves curative, and must 
be done when other means fail. Symptomatic and supporting 
treatment. 

Empyema invariably requires surgical interference. Open 
abscess if it points. Aspiration is not satisfactory. Supply 
free drainage by openings anterior and posterior, with free 
incisions into pleural cavity; cleanse twice daily with mild 
antiseptic solutions of boric acid, creolin, carbolic acid, or 
hydrogen peroxide. Most nutritious diet ; iron, quinine, phos- 
phates, cod-liver oil, and stimulants as indicated. To tins 
combine best hygiene and careful nursing, with thorough 
antiseptic measures. 



340 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



PNEUMOTHORAX. 

Definition. — A condition resulting from disease or injury, 
in which air has entered the pleural cavity through the lungs 
or chest- walls. 

Etiology. — Tubercular ulceration • breaking of abscesses ; 
empyema ; perforation of chest- walls 5 or any means that may 
destroy the continuity of lung structure or chest-walls and 
permit air to enter. 

Symptoms. — Vary according to cause. Acute cases com- 
mence with a sudden, sharp pain in the side ; a feeling of 
something giving way ; great dyspnoea ; small pulse ; profuse 
sweat 5 and threatened collapse. Respiration rapid and shal- 
low ; intercostal spaces depressed 011 inspiration ; affected 
side of chest bulging and enlarged. Paroxysmal cough. Per- 
cussion note tympanitic or hyper-resonant. Vesicular murmur 
lost or diminished ; amphoric respiration ; metallic tinkling, 
if effusion be present. Pleurisy is developed from irritation 
of air. 

Pathology. — That of cause. Air in pleural cavity, if in- 
closed, may be absorbed. It acts as an irritant ; sets up 
inflammation, which is followed by effusion, which is gen- 
erally infected with pyogenic germs and causes empyema. 

Diagnosis. — Emphysema is always bilateral, with a differ- 
ent historjr of onset. 

Prognosis. — Very bad. Most probable termination is 
death, unless due to traumatism or surgical means. 

Treatment. — Hypodermic injection of morphiua and atro- 
phia to relieve pain, cough, and excitement. Follow with 
small doses of opium if indicated. Over-distention with air 
indicates aspiration or puncture of chest- walls and introduc- 
tion of a metallic tube with a valve that allows air to escape 



DISEASES OF THE PLEURA. 341 

but none to enter. The inclosed air may absorb without 
surgical means. Treat effusion as in pleurisy and empyema. 
Best nutritious diet; stimulants; tonics; and constant out- 
door life in best atmosphere. 

HYDROTHORAX. 

Definition. — Dropsy of both pleural cavities, secondary to 
some other affection. 

Etiology. — Bright's disease ; valvular heart-diseases ; ob- 
struction to pleural circulation by cancer or tumors. 

Description. — Serous effusion into both pleural cavities is 
slow in onset, without acute symptoms, and accompanies 
general dropsy. Dyspnoea gradually increasing; symptoms 
of causative disorder; dullness on percussion; diminished 
respiratory murmur. Effusion may become purulent and is 
termed hydro-pyo- thorax. 

Prognosis. — Depends on causative trouble. 

Treatment. — Causative. — Aspiration is only palliative, as 
fluid returns. Dry diet ; salines and drastics, if patient can 
endure them ; limit amount of liquids taken ; treat symptoms. 



THE NERVOUS SYSTEM. 

INTRODUCTION. 

The nervous system is a complete whole, and for purpose 
of study is subdivided into the cerebro-spinal axis and the sym- 
pathetic system. The cerebro-spinal axis consists of the brain, 
spinal cord, medulla oblongata, and the nerve-trunks origi- 
nating from them. The sympathetic nervous system is a series 
of ganglia lying on each side of the spinal column, connected 
by commissural fibers, and extending from the ganglion of 
Ribes, on the anterior communicating artery at the base of 
the brain, to the ganglion of Impar, in front of the coccyx. 
Every sensation, motion, physiological and pathological action 
is dependent on direct and reflex nervous action. 

Reflex nerve-action is a stimulation and transference of an 
impression through an afferent nerve to a nerve-center, and 
its return through an efferent nerve to the parts, causing mo- 
tion or physiological action. It is either motor, secretory, 
tactile, or inhibitory. 

Localization of Senses and Functions. — Every sense and func- 
tion is dependent upon the action of a certain group of nerve- 
cells distinctly localized in the brain or spinal cord, which 
communicates with the parts by means of nerve -fibers. Any 
disease of or interference with these nerve-centers or their 
communicating nerves results in a physiological impairment 
of the parts governed by them, and it is by this method that 
nervous diseases can frequently be localized. 

Diagnosis of nervous diseases is dependent on symptoms 
only. 

342 



THE NERVOUS SYSTEM. 343 

MOTION. 

Every muscle is endowed with a certain physiological mo- 
tion that must be studied in health to be recognized. Impair- 
ment of the nerves supplying that muscle, be it voluntary or 
involuntary, produces (1) paralysis, partial or complete ; (2) 
convulsions, tonic (constant) or clonic (interrupted) ; (3) inco- 
ordination — the inability to produce voluntary muscular move- 
ments in proper order, most marked when the eyes are closed. 

SENSATION. 

Sensation is the recognition of impressious made upon the 
peripheral sensory nerve-organs of the body, and recognizes 
touch, pain, heat, and cold. A loss of sensation, partial or 
complete, is termed ancesthesia. When there is insensibility 
to pain, it is termed analgesia, Polywsthesia is a pathological 
sensation in which the contact of one point produces the sen- 
sation of several. Hyperesthesia is an increased, sensibility. 
Hyperalgesia is increased sensibility to pain. 

ELECTRICAL REACTIONS. 

Every muscle and nerve, in a physiological state, will give 
a certain reaction when stimulated by electricity. In these 
examinations, use is made of the galvanic, faradic, and static 
currents. 

Galvanic electricity is a primary, constant current, with two 
distinct poles — a positive pole (anode) and a negative pole 
(kathode). The ayiode is sedative in its action-, the kathode is 
irritant. Four special reactions are noted in the use of gal- 
vanism : 

(1) When the anode is placed over the spinal center and 
the kathode is brought in contact with the skin over a muscle 



344: A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

or nerve, there is a reaction or contraction, called the Jcathodal 
closing contraction (KCC). This is due to closing the circuit. 

(2) When the kathode is raised from the body, there is 
another contraction, called the Cathodal opening contraction 
(KOC), caused by breaking the circuit. 

(3) Reverse the order by placing the kathode over the spinal 
center and the anode over the muscle or nerve, and when ap- 
plied there is a contraction — anodal dosing contraction (ACC). 

(4) When the anode is removed from the muscle or nerve, 
we have an anodal opening contraction (AOC). 

These reactions must be studied in health, and according 
to their impairment so are we able to diagnose many nervous 
diseases. (See appropriate works on electricity.) 

Faradic electricity is an interrupted, induced, or secondary 
current, whose poles are never constant, except in the prim- 
ary coil. The two poles are usually applied over the same 
muscle at once, and a series of clonic contractions ensues if 
the interruption of the current is slow, or tonic if the inter- 
ruption is very rapid. 

Static electricity is derived by friction ; stored in Leyden 
jars; used directly by sudden discharges of the electric 
spark into the different muscles ; or by the production of the 
static breeze. 

Reaction of degeneration is a diminution or loss of response 
to the faradic current, with no impairment or a slight increase 
of galvanic excitability, which may also diminish or be lost, 
indicating a lesion of the peripheral nerves or spinal cord. 

TROPHIC CHANGES. 

Nervous disorders always produce some nutritive disturb- 
ance in one or more parts of the body : wasting of the mus- 
cles ; falling of the hair ; impairment of nail-growth ; ulcera- 
tions; eruptions on the skin; and disorders of the special 
senses, 



THE NERVOUS SYSTEM. 345 

REFLEXES. 

The reflexes of the body afford a valuable index to the diag- 
nosis of nervous diseases, and are classed as the superficial or 
cutaneous reflexes and the deep or tendon reflexes. Scapular 
reflex is a contraction of the scapular muscles when the skin 
between the shoulders is irritated. Plantar reflex is a contrac- 
tion of the plantar muscles when the sole of the foot is tickled. 
Gluteal reflex is a contraction of the gluteal muscles on stimu- 
lation of the skin over them. Cremasteric reflex is a retraction 
of the testicle on the same side when the inner and upper 
part of the thigh is irritated. Abdominal reflex — contraction 
of the abdominal muscles when irritated. 

Tendon Reflex. — Strictly speaking, there is no tendon reflex, 
as the contraction is not done by the tendon, but by the 
muscle to which it belongs. If the ligamentum patella or 
tendinous part of the rectus femoris muscle is struck a smart 
blow when the one leg is crossed loosely over the other and 
hanging in a slightly flexed state, there is a contraction of the 
muscle, called the patellar reflex or knee-jerk. 

Clonus is a reflex, irregular contraction of a muscle when 
suddenly stretched and held in that position. Clonus mani- 
fests itself best when the foot is suddenly flexed on the leg, 
by a series of rhythmical contractions of the gastrocnemius 
and soleus muscles, numbering from six to nine in each sec- 
ond (anMe-clonus). 

Other valuable symptoms must be noted. Derangement of 
the special senses and the power of intellection, tremors, 
delirium, insomnia, and vertigo afford valuable diagnostic 
indices, 



THE NEUROSES. 

A neurosis is a functional disturbance of the nerve-centers, 
whose pathology is not positively known. 

CHOREA. 

Synonym.— St. Vitus's dance. 

Definition. — A functional nervous affection, manifesting 
itself by a series of involuntary, arhythmieal, spasmodic, mus- 
cular movements affecting one or more groups of muscles. 

Etiology — It is most commonly found in children, and is 
caused by reflex irritations, fright, masturbation, worms, 
genital defects, intestinal parasites, painful dentition, and 
direct injury. Rheumatism produces many cases. It seems 
to be hereditary in some families. Female children are more 
frequently affected than male. It has appeared as an epi- 
demic among ignorant classes who were susceptible to great 
mental impressions, and is termed hysterical chorea. 

Symptoms. — Gradual onset. Child cannot remain still in 
one position for one minute, but is constantly fidgeting about 
Among many movements is a peculiar jerking of the head; 
distortion of expression ; spasmodic closure of eyelids ; open- 
ing the mouth ; protruding the tongue ; oscillation of the eye- 
balls (nystagmus) ; jerking of arms and legs ; spasmodic closure 
of hands ; and spasmodic speech. In fact, every effort is made 
spasmodically. Child often utters peculiar cries or certain 
favorite expressions, and has a very excitable temperament. 
Urine or faeces may be voided involuntarily in severe cases. 
Choreic movements continue at all times when the patient is 
awake ; are always aggravated by motion or excitement ; and 
usually absent during sleep. In mild cases these movements 

346 



THE NEUROSES. 347 

can be controlled by an effort of the will. Mental state is 
lowered. Increased electrical excitability. Sensations are 
usually normal. Heart is irregular, tumultuous, and gives a 
systolic murmur at the apex in more than half of the cases. 
The severer forms ultimately terminate in paralysis and in- 
sanity. Choreic children always have a great desire for 
masturbation, and very excitable genital organs. 

Chorea may be of all grades, from the slightest muscular 
contraction to the most violent, in which the patient can 
neither stand, talk, nor accomplish voluntary motion. Hemi- 
chorea is an affection confined to one side of the body. 

Pathology. — No distinct pathological lesion has ever been 
differentiated. It is undoubtedly due to some irritation of 
the central nerve-centers, but the how, where, and when are 
questions for future pathological investigation. 

Diagnosis. — See table, Paralysis Agitans. 

Prognosis. — If the exciting cause can be removed, the dis- 
ease subsides quickly under proper attention. Neglected 
cases become worse and may iiltimately terminate in paral- 
ysis, insanity, or chronic chorea. Confirmed masturbation 
always leads to an increase of the trouble, and saps both 
physical and mental strength. In heart-lesions the prognosis 
is rather unfavorable. 

Treatment. — Cause. — Inquire carefully into the history of 
the case, and never neglect a thorough physical examination of 
every organ in the body. Remove every possible cause, and 
bring into activity the whole secretory and excretory system. 
Absolute plrysical and mental rest is imperative. Masturba- 
tion must be prevented, regardless of the measures necessary. 
Patients of this class should never be frightened, excited, or 
made the subject of ridicule. Nutritious diet suited to the 
digestive powers. 

Medicinal Treatment. — Administer hypnotics at night if 



348 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

sleep cannot be obtained. Liq. potassii arsenitis, n l iii-v, 
after meals, gradually increased to the point of tolerance, is 
the most common remedy used. Zinc salts, given three times 
daily, are advised by some. Hyoscyamns, cimicifuga, iron, 
and antispasmodics. Acetanilide, phenacetin, and antipyrin 
are new remedies used. Strychnina or ignatia will benefit 
some cases. Massage, salt-water baths, and electricity. Mild 
cases should be controlled by the influence of the will as far 
as possible. Treat complications. 



EPILEPSY. 

Varieties. — 1. Epilepsy major, limit mdl or le grand mat; 
2. Epilepsy minor, le petit mat, abortive epilepsy or epileptic 
vertigo ; 3. Jacksonian or partial epilepsy. 

Definitions. — Epilepsy major is a sudden, complete loss of 
consciousness and coordination, accompanied by tonic or 
clonic muscular convulsions, of short duration, and tends to 
recur at irregular periods of time. 

Epilepsy minor is a slight, temporary loss of consciousness 
without loss of coordination, occasionally accompanied by 
tonic or clonic muscular contractions. 

Jacksonian epilepsy is a temporary tonic or clonic spasm of 
one or more groups of muscles on the same side of the body, 
without loss of consciousness, and recurs at irregular intervals. 

Etiology. — Inherited. Patients with cerebral tumors, 
chronic meningitis, fractures of the skull, syphilis, and nerv- 
ous disorders are often affected with one of the varieties of 
epilepsy. No distinct cause has been found. 

Symptoms. — Epilepsy Major. — Immediately preceding the 
attack, and lasting from a few seconds to a few minutes, is 
the epileptic aura. This consists of various sensations in 



THE NEUROSES. 349 

different persons. A hot or cold wave seems to spread grad- 
ually from the tips of the fingers or toes to the whole body ; 
sensations of tingling or numbness extend from the extrem- 
ities ; strange feelings about the abdomen or chest ; and the 
appearance of certain peculiar visions. 

Immediately following the aura is a sudden loss of con- 
sciousness, usually preceded by a characteristic cry, and the pa- 
tient falls very hard, if standing, and is often seriously injured. 
Skin is pale and cold, and muscles are in a state of tonic con- 
traction for a few seconds or minutes. Clonic convulsions 
soon follow. The thumbs are pressed firmly into the palms. 
Tongue is often severely bitten. Conjunctivae are absolutely 
free from sensation, and the pupils do not respond to light 
during the attack. Saliva is blown from the mouth like foam. 
Following the attack is a condition of drowsiness, stupor, or 
coma, which lasts from five minutes to several hours. Pulse 
rather full and slightly accelerated. Respiration is deep, full, 
and labored. Consciousness returns gradually; intellection 
is dazed for a time ; quite nervous ; skin is cold and pale, and 
covered with cold sweat. Headache follows an attack. Al- 
buminuria is not uncommon. 

Epilepsy Minor. — A person during conversation or at work 
will be seized by a sudden loss of consciousness, with rigid- 
ity, or, possibly, a slight twitching, of one or more groups 
of muscles, lasting for a few seconds only, when he resumes 
his work or conversation where he stopped, usually uncon- 
scious of the attack. Occasionally the sensation is only 
that of a passing dizziness. These patients rarely fall or cry 
out. There is no aura. Headache, weakness, or nervousness 
follows. 

JacJcsonian Epilepsy. — Some authors question the propriety 
of classing this phenomenon as epilepsy, but the main symp- 
tom consists of irregularly recurring clonic convulsions that 



350 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

affect one or more groups of muscles, always on the same side 
of the body, without the epileptic aura or loss of conscious- 
ness. An attack lasts from one to fifteen minutes or longer. 

General Considerations. — Epileptic patients are usually anae- 
mic, nervous, inactive, and intellectually dull. They are irri- 
table, quick-tempered, and often demented. Occasionally one 
meets with an epileptic who is apparently in perfect health. 
The attacks come at irregular intervals, according to the ex- 
citing conditions. They may occur many times in one day, 
weekly, monthly, or yearly. Every convulsion tends to in- 
crease the difficulty. 

Pathology. — Epilepsy is classed as a nerve-storm, and is 
dependent upon some peripheral or central exciting cause. 
No definite pathological lesion has yet been found ; hence the 
pathology is uncertain. 

Diagnosis. — Malingering. — Rarely injure themselves when 
falling, and do not bite their tongue ; skin is natural in color ; 
conjunctiva is sensitive, and pupils respond to light ; can be 
made to sneeze by blowing snuff into the nostrils or tickling 
the nose with a feather ; reflexes are unimpaired, and there 
is sensibility to pain. 

Hysterical epilepsy is characterized by violent muscular ac- 
tion and resistance when held ; rarely bite the tongue or injure 
themselves in falling ; duration is longer than true epilepsy ; 
sensibilit} T is little impaired ; pupils react to light ; and patient 
is of an hysterical temperament. 

Prognosis. — Epilepsy, in a small percentage of cases, is 
curable. Hereditary epilepsy usually persists through life. 
Surgical operations may prove efficacious in some cases. 
Rarely fatal per se, but death may be caused by injury in fall- 
ing. The mental condition gradually grows worse in severe 
cases. Convulsions sometimes disappear for years and then 
return. 



THE NEUROSES. 351 

Treatment. — Buying a convulsion, nothing can be done 
except the prevention of personal injury. Something soft — a 
block of wood, or cloth — should be forced between the teeth 
and held there to prevent biting the tongue. Lay patient flat 
on the floor and remove any clothing that may impede respi- 
ration. See to it that false teeth do not remain in the month. 
Cold water applied to the head often facilitates a return of 
voluntary functions. Inhalations of ammonia, amyl nitrite, 
and camphor are of little use except at the commencement of 
the aura. 

Preventive. — Remove every abnormal condition if possible. 
Forbid the use of tobacco in any form, masturbation, and 
all excesses. Give best diet, bring into activity every gland 
in the body, and endeavor to establish a normal physiologi- 
cal condition. Search for and remove all possibility of intes- 
tinal parasites. In anaemia, give tonics of iron, arsenic, and 
strychnine. 

ft 

Acidi arseniosi. 

Strychnines sulphatis aa. gr. -£$. 

Ferri redacti gr. ij. 

Ext. belladonnas gr. -^ . 

Misce. Fiat in pil. No. 1. Signa. One after each meal, 
continued for several weeks or months. 

The bromides, in doses of twenty to thirty grains, three or 
four times daily, are the favorite remedies to abort or pre- 
vent convulsions. They must be given for weeks and months 
to be of efficacy. Great harm may result from their pro- 
longed administration, and their effects must be watched 
closely. When the aura begins in one of the extremities, the 
convulsion may be avoided by tightly constricting the mem- 
ber near the body. Salts of zinc, copper, silver, nickel, bella- 



352 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

donna, hyoseyamus, and many other remedies are recom- 
mended in varying doses. Change of climate will occasionally 
influence some cases favorably. Electricity. 

Minor and Jacksonian epilepsy are treated on the same 
general plan as epilepsy major. 

HYSTEEIA. 

Description. — Hysteria is a functional nervous disease eon- 
fined principally to women, and manifests itself by different 
nervous phenomena. Hysterical patients are usually of a 
very excitable temperament, and often inherit their predis- 
position. One attack predisposes to another. During the 
intervals the patient may be in perfect health and rational ; 
or there may be a constant irritability of temper and the spe- 
cial senses. Anger, excitement, worry, grief, fatigue, fright, in- 
jury, or sickness, all give rise to attacks. Ovarian and womb 
diseases are accountable for many cases. 

Hysterical attacks assume various forms. There is always 
a complete loss of self-control. They cry, laugh, moan, 
scream, or have wild delirium, but are always conscious of 
what is going on around them and desire sympathy. They 
often resort to various means of simulating certain general 
or skin diseases, as by applying or taking drugs. Anaes- 
thesia or hyperesthesia of certain portions of the body, in- 
tolerance of noise, light, or certain odors, are common mani- 
festations. Dyspnoea, aphonia, and temporary paralysis of 
one or more groups of muscles, without disturbance of the 
electrical reactions. Sometimes they assume a state of cata- 
lepsy or trance. Irregular tonic or clonic convulsions occur 
at long or short intervals. Headache is quite common. 
The globus hystericus is a sensation produced in the throat 
and oesophagus by the supposed presence of a lump or ball 



THE NEUROSES. 353 

that " moves tip and down and is abont to strangle " them. 
In short, there is no known condition that hysterical subjects 
will not simulate. 

Pathology. — No definite pathological lesion has been found. 
Many cases are caused reflexly by ovarian and womb troubles ; 
others are caused by unbalanced mental equilibrium • while 
many are entirely inexplicable. It seems to be a nerve-storm. 
One writer sa} T s : "It is simply a manifestation of satanic in- 
fluence entirely beyond the control of the will of the subject." 

Diagnosis. — Most cases recover in time, with or without 
treatment. Marriage and the birth of children cures some 
cases. Death may ensue from a prolonged attack. Insan- 
ity, with homicidal and suicidal tendencies, terminates a small 
percentage of the cases. 

Treatment. — Examine your patient thoroughly, and re- 
move every trace of disease if possible. Institute the very best 
hygienic, moral, and psychical surroundings, and stimulate 
the general glandular system to activity. No definite rules 
can be given for treatment. Each case must be dealt with ac- 
cording to its indications. Sympathy and kind treatment 
may answer best in some cases, while others demand nothing 
but harsh, severe treatment. 

Absolute isolation and a diet of bread and water is specific 
with many. A sudden bath of ice-cold water often brings 
about a rational condition most effectually. Corporal pun- 
ishment is occasionally demanded with young girls. Electric- 
ity and massage. Valerian, asafcetida, and other antispas- 
modics will often prevent attacks. 

Do not administer morphina, but have recourse to the anaes- 
thetics if necessary. When food is refused, administer it forc- 
ibly per rectum or with the stomach-tube — one or two such 
treatments will suffice. It is absolutely necessary for the phy- 
sician and the nurse to impress the patient with the fact that 



354 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

you mean business, and that they must be dealt with with an 
unswerving hand — otherwise treatment is most unsatisfactory. 

THOMSEN'S DISEASE. 

Description. — This rare disease, whose pathology is still a 
question of uncertainty, is characterized by a sudden rigidity 
of one or more groups of muscles whenever voluntary motion 
is first attempted after a long or short period of rest. It lasts 
but a few seconds and then permits voluntary motion. Every 
attempt to get up, run, walk, or act quickly is always preceded 
by this rigidity of the muscles. Excitement, cold, fright, and 
fear aggravate it. It is often hereditary, and affects the ex- 
tremities principally. No lesion of the nervous system has 
been discovered. The muscles are slightly hypertrophied, and 
respond rather slowly to the galvanic current. Muscular 
hypertrophy is probably caused by the excessive rigidity and 
muscular activity rather than the disease itself. It is rarely 
fatal, and may continue for years. 

Treatment is entirely symptomatic and empirical. It is 
sometimes called congenital myotonia. 

NEURALGIA. 

Definition. — Neuralgia is a functional disease characterized 
by pain along the course and distribution of one or more sen- 
sory nerves, and must be differentiated from the pain pro- 
duced by definite pathological conditions of the nerve sheaths, 
trunks, and centers. 

Etiology. — Most common among young adult females and 
in middle life. There is a peculiar nervous diathesis that is he- 
reditary in some families, which accounts for many obstinate 



THE NEUROSES. 355 

cases. All forms of nervous complaints, gout, rheumatism, 
anaemia, debility, ocular defects, fatigue, excitement, improper 
exercise and food, and close confinement predispose to neu- 
ralgia. 

Among exciting causes are exposure to cold and wet, reflex 
irritation from carious teeth, inflammation of the uterus, 
metritis, malaria, syphilis, alcoholism, and metallic poisons. 

Symptoms. — Neuralgia is sudden in onset, and usually con- 
fines itself to one group of nerves and their area of distribu- 
tion. There is no fever, redness, nor swelling at first. Pre- 
ceding an attack the skin is often anaesthetic for several hours. 
The pain intermits and remits, at times being sharp, shooting, 
and lancinating, and again dull, boring, or aching. In old 
chronic cases or prolonged acute cases tender points are found 
along the course of the nerves, usually at the points of exit 
through bony or fibrinous foramen. The duration of an at- 
tack varies from a few hours to several days or a week. Dur- 
ing and following an attack, the skin covering the area of 
distribution of the affected nerve is sore and sensitive to press- 
ure. Trophic changes are liable to occur in severe or pro- 
longed cases, such as altered secretions, congested capillaries, 
falling of the hair and change of its color. The special 
symptoms of neuralgia vary according to each group of 
nerves involved. 

Trifacial neuralgia (tic-douloureux) involves one or more of 
the three divisions of the fifth cranial nerve, and is one of 
the most common forms. When the first or ophthalmic division 
is involved, pain is most severe in the forehead, eyelids, eye, 
and side of the nose. There is increased lachrymation, and 
discharge from the nose of a thin, watery character. Tender 
points are found at the supra- orbital foramen, side of the nose, 
and on the eyeball. The second or superior maxillary division 
causes pain in the cheek, nose, upper teeth, and jaw, and pre- 



356 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

sents tender points on the malar bone, nose, and superior 
maxillary bone. The third or inferior maxillary division refers 
pain to the inferior maxillary bone, temporal and parietal 
regions, ear, and tongue, with tender points at the inferior 
dental foramen, on the zygomatic arch, and in front of the ear. 

Cervico-occipital neuralgia is sharp, shooting, continuous, 
often bilateral, and extends from the neck to the occipital re- 
gions, to the cheeks, and down the neck to the clavicles. This 
form is usually excited by carious teeth or exposure to cold. 

Cervico-brachial neuralgia produces paroxysms of pain in the 
fingers, arms, scapular region, the back and side of the neck. 
There is a tingling, numb feeling in the arm and hand, as if 
" asleep." 

Intercostal neuralgia occupies the distribution of the inter- 
costal nerves, and is usually accompanied by a vesicular erup- 
tion called herpes zoster. 

Lunibo-abdominal neuralgia manifests itself by parox3 T smal 
pain in the lower part of the abdomen, back, iliac regions, 
scrotum, and anterior aspect of the thighs. Herpes is occa- 
sionally present. Caused by malarial poisoning. 

Sciatica, usually classed as neuralgia, is considered sepa- 
rately as an inflammatory affection. (See p. 368.) 

Pathology. — The pathological process involved in neural- 
gia is a question of doubt. It is undoubtedly a functional 
disease primarily, but is soon complicated by neuritis and 
allied troubles. 

Diagnosis. — Absence of all organic lesions or obstructions j 
sudden, sharp, shooting, paroxysmal pain ; tender points along 
the course of nerve ; absence of fever and inflammation ; usu- 
ally confined to the distribution of one set of nerves ; trophic 
changes ; and, in chronic cases, a peculiar nervous diathesis. 

Prognosis. — If promptly treated, the majority of cases re- 
cover, but relapses are quite common. Chronic cases afford 



THE NEUROSES. 357 

discouraging prospects for permanent results, although many 
are benefited temporarily. 

Treatment. — In every case seek for the cause, and, if pos- 
sible, remove it. Such reflex causes as carious teeth, metritis, 
gastritis, and allied disorders must be treated. Anaemia, syph- 
ilis, debility, and alcoholic excesses require appropriate treat- 
ment before permanent results can be obtained. The very 
best, most nutritious diet must be given. Cod-liver oil in the 
weak and anaemic, provided it can be digested. Tonics of 
iron, quinine, phosphorus, and strychnine are the best rem- 
edies for chronic cases. 

Resinae phosphori gr. ■£$. 

Strychnin ae sulphatis gr. to - * 

Quininae bisulphatis gr. ij. 

Ext. belladonnae gr. \. 

Acidi arseniosi gr. ifo- 

Misce. Fiat in pil. No. 1. Signa. One pill three times daily 
for two weeks, then drop the phosphorus and continue with 
the rest of the prescription for one week, only to resume the 
phosphorus again for the next two weeks, and so continue for 
months. 

During the paroxysm, order your patient to lie down quietly 
in a dark room, and administer a pill of acetanilide, quinine, 
and cocaine every fifteen or thirty minutes until relieved. 
(See formula, p. 27.) 

Phenacetin may be given in doses of one to ten grains. 
Antipyrin, given in five-grain doses, although it will some- 
times relieve a paroxysm, should be used with great caution. 
Trinitrin (one-percent, sol.), gtt. j, every hour, will often 
relieve obstinate cases. Aconite and belladonna, given in 
combination, are useful. MorpJiina must be given only after all 



358 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

other remedies fail. Counter-irritation with mustard, blisters, 
liniments, heat, or cold, over the painful points, will produce 
great relief. 

A mild current of galvanic electricity, properly applied, is 
one of the most certain curative measures at our command. 
Place the positive pole over the painful spot and the negative 
pole over some neutral point, and pass from two to five mil- 
liamperes for five or twenty minutes. Repeat as often as nec- 
essary. Surgical measures have been resorted to, such as 
neurotomy, neurectomy, and nerve-stretching, with varying 
degrees of success. 

MIGRAINE. 

Synonyms. — Megrim j sick-headache. 

Description. — Migraine is dependent upon many causes. 
It is frequently hereditary in nervous and gouty families j most 
common in young adult females who lead sedentary lives and 
are surrounded by improper hygiene. Indigestion, constipa- 
tion, eye-strain, anxiety, grief, fright, fatigue, and defects of 
vision predispose and excite paroxysms. 

Onset is usually preceded by one or more sensory symp- 
toms, viz., dimness of vision ; floating, bright spots before the 
eyes j tingling sensations in the arms, hands, feet, face, and 
tongue ; aphasia in severe cases ; temporary, partial paralysis ; 
and a sense of general uneasiness and restlessness — frequently 
fear of impending death. 

Accompanying or following these sensory impressions is 
headache, which varies from a dull, heavy feeling in the head 
to a very sharp, throbbing pain, mostly on one side of the 
head (hemicrania). Occasionally the pain centers in the eye, 
temple, ear, or forehead, and is increased by motion, noise, 
and excitement. Face is pale ; skin cold and clammy ; pulse 



THE NEUROSES. 359 

feeble and slow: but the contrary conditions may exist in 
certain cases. Lachrymal and salivary secretions are often 
greatly increased. 

Migraine is periodical in its course, and may appear daily, 
weekly, monthly, or at any uncertain period. It is rarely 
dangerous, and may in time be replaced by attacks of epilepsy, 
asthma, or some other nervous affection. 

Vomiting is characteristic; consists of bilious material; is 
most common during the height of the paroxysm; and fol- 
lowed by temporary or permanent relief. 

During the intervals, patient is in perfect health, or may 
suffer from slight headache and nervousness. 

Treatment. — During a paroxysm, lie in a dark and quiet 
room, with cold compresses to the head. Vomiting will pre- 
vent analgesic drugs from acting, and it is well to administer 
as much warm water as can be taken, to cleanse the stomach 
of bile and food. After this, admirable results are obtained 
by giving : 

Cupri arsenitis gr. tot • 

Tr. nucis vomicae f 3 ss. 

Aquae f 1 iv. 

M. Signa. One teaspoonful every ten minutes until re- 
lieved. 

Pill acetanilide comp. (form, p. 27), every half -hour ; full 
doses of phenacetin, acetanilide, sodium salicylate, or bro- 
mides, if retained, afford prompt relief. Trinitrin, in certain 
cases, is very good. Avoid opium and its preparations. . 

During the interval, break up sedentary habits ; correct con- 
stipation and indigestion ; carefully regulate diet according to 
individual requirements ; correct all defects of vision ; insist 



360 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

on daily exercise in the open air ; attend carefully to hygiene. 
Administer tonics of iron, arsenic, strychnine, cod-liver oil, 
and others, as indicated in neuralgia ; attacks can frequently 
be averted by rest in bed and full doses of phenacetin, acet- 
anilide, quinine, bromides, or the prescription given above. 

PARALYSIS AGITANS. 

Synonyms. — Shaking palsy ; Parkinson's disease. 

Definition. — A disease of old persons, recognized by con- 
stant rhythmical contractions of the muscles of the extremi- 
ties, head, and neck, partially under the control of the will, 
absent during sleep, and increased by excitement or physical 
exertion, together with weakness and rigidity of the muscles. 

Etiology. — Begins after the fortieth year, and is more 
frequent among men than women. No distinct cause can be 
determined, although it often dates from a severe fright, nerv- 
ous shock, injury, exposure, or some acute disease. 

Symptoms. — Onset is slow and begins in one or more groups 
of muscles, causing alternate flexion and extension of the fin- 
gers, wrist, arm, leg, or parts affected. These contractions 
average from five to eight in a second ; gradually spread to 
the corresponding parts on the other side of the body, and 
may finally involve most of the voluntary muscles. At first 
they can be controlled temporarily by an effort of the will, 
but otherwise continue during the hours of waking, and are 
absent during sleep. Speech is not affected ; writing is ir- 
regular and characteristic j nystagmus is absent. 

Muscular weakness and rigidity precedes, accompanies, or 
follows the trembling ; grasp of the hand is weak • and every 
slight effort causes excessive fatigue and profuse sweating. 
Muscular movements become slow and difficult ; the muscles 
assume a rigid form, without hypertrophy, and when patient 



THE NEUROSES. 



361 



begins to walk he either stumbles until he falls or is unable 
to stop or turn without assistance 5 equilibrium is easily lost. 

Complete paralysis is the ultimate result in two to twenty 
years. Complications are bed-sores, headache, vertigo, dis- 
eases of the lungs, and exhaustion. No pathological process 
or lesion is demonstrable. Recovery is the exception. 



Diagnosis. 



Paralysis Agitans. 

A disease of old age. 

Rhythmical move- 

ments. 

Speech unaffected. 

No nystagmus. 

Movements slightly in- 
creased by motion. 

Can take food and 
drink without aid. 

Constant movements 
during waking hours. 



Chorea. 

Disease of childhood. 

Arhythmical, spasmod- 
ic movements. 

Natural or spasmodic. 

No nystagmus. 

Movements increased 
by motion. 

Can take food and 
drink without aid. 

Movements not con- 
stant ; irregular. 



Mult. Spinal Sclerosis. 

Adults or children. 
Irregular movements. 

Scanning speech. 

Nystagmus. 

Great increase of move- 
ments by motion. 

Unable to drink from a 
cup without spilling. 

No movements except 
during voluntary ex- 
ertion. 



Treatment. — Entirely symptomatic, for no known remedy 
will cure. Barium, arsenic, iron, and strychnine have been 
used, but the improvement noted in a few cases may have 
been a coincidence, as the disease often ceases spontaneously 
without treatment. Galvanism and faradism may be benefi- 
cial. If movements become very painful, administer sedatives. 
Institute best diet and hygiene. Treat all complications. 
M. Charcot has devised a mechanical chair and helmet which, 
by a series of rapid vibrations, is used in treating these cases. 
Great relief is afforded; the trembling disappears or is re- 
duced temporarily j the muscular stiffness ceases. 



362 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



NEURASTHENIA. 

Description. — Neurasthenia is a deficiency or exhaustion of 
nerve-force, together with debility of the nervous centers, 
manifesting itself in both sexes. It is caused by prolonged 
excitement, worry, study, family and business troubles, pro- 
longed sickness, fright, traumatism, indigestion, inheritance, 
excessive venery, alcoholism, and the use of narcotics. 

Such persons find their power of endurance and concentra- 
tion of thought impaired 5 trifling things worry and irritate 
them; they become fretful, dissatisfied, irritable, cross, or 
tyrannical ; hysterical or hypochondriacal ; have headache and 
insomnia 5 start up from sleep ; general nervousness j loss of 
appetite, and suffer from indigestion; emaciation slight or 
marked ; constipation ; general anaemic and sallow complex- 
ion ; and a peculiar, piercing, sharp eye. 

Tender points are often found along the spine, with sharp 
or dull tingling pains along the course of one or more nerves. 
Temporary or permanent paralysis may result. Neurasthenia 
is functional in character, and entirely beyond the control of 
the will. There is a tendency on a neurasthenic's part to 
conceal the trouble until the very last moment. Recovery 
is the rule. 

Treatment. — Absolute rest and freedom from business 
and family cares, with an endeavor to take the patient's mind 
off himself and keep it occupied with some light and amusing 
thoughts. Never allow him to converse or dwell upon his 
ailments or trials. Diet must be light, nutritious, and suited 
to his power of digestion. Let him feel that you are doing 
something and are interested in his case, for a good mental 
impression is nearly as good as drugs. 

Absolutely avoid opium and use a minimum amount of seda- 



THE NEUROSES. 363 

tires, for they are temporary in their action and followed by 
"bad results and habits. A season at some. chalybeate or other 
mineral spring, nnder the care of a physician, is often cnrative. 
Galvanism, faradism, and massage all play important parts as 
curative agents. Exercise judgment in the administration of 
tonics, as each case will require special study and medicinal 
treatment suited to it. 

WRITERS' CRAMP. 

Synonyms. — Writers' palsy ; graphospasm ; mogigraphia. 

Definition. — A temporary or permanent, partial or com- 
plete paralysis of the muscles of the fingers, hands, and wrist, 
with incoordination, occurring in those who use these muscles 
for a prolonged period of time. 

Etiology. — More common in men from eighteen to fifty, 
from the fact that they are more frequently employed at the 
work that predisposes to it, and especially so if there is a his- 
tory of hereditary nervousness. May be caused by a local in- 
jury to the muscles or nerve-trunk, but usually comes from 
prolonged use and over-exertion of a group of muscles by 
writing, telegraphing, type- writing, piano-playing, or fine 
work. 

Symptoms. — Onset is slow, manifesting itself first by a 
tired feeling in the muscles of the fingers, wrist, and arm ; 
this is replaced by stiffness and a slight aching, until finally 
the muscles contract painfully, cause irregular writing, and 
may produce a tonic or clonic spasm of the muscles which 
will last several minutes. Rest for a short time affords tem- 
porary relief, but it soon returns if work is resumed. Elec- 
trical reaction is not usually affected. Pain may be neuralgic 
in type. Certain cases manifest themselves only by tremor 
during efforts to use those particular muscles. 



364 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Treatment. — Preventive. — If compelled to do much writing, 
use finger, wrist, and arm movements at alternate intervals, 
to avoid prolonged use of one group of muscles. If possible, 
use a type- writer for a time. Always avoid a tight grasp on 
a pen or any other instrument. 

Active Treatment — Absolute rest of the affected muscles is the 
only certain process of cure. All proposed methods of hold- 
ing and using the pen are but temporary expedients and of 
little avail in the end. Active massage of each muscle, gal- 
vanism, and inunctions of hot olive-oil are most beneficial. If 
neuritis is present, treat as indicated. Build up the general 
system with tonics and proper food. Always warn your 
patients that relapses are quite common if their old habits 
are resumed. First of all learn the proper method of caring 
for your own muscles, then instruct your patients. 



DISEASES OF THE NERVES. 



NEURITIS. 

Definition. — Neuritis is an inflammation of a nerve-trunk, 
recognized by pain, loss of power, redness and tenderness 
along its conrse. 

Perineuritis is an inflammation of the nerve sheaths and 
coverings, with manifestations similar to those of nenritis. 

Etiology. — Traumatism; exposure to damp and cold; ex- 
tension from other parts j chemical causes ; secondary to acute 
diseases, such as rheumatism, variola, diphtheria, syphilis, and 
lead-poisoning. 

Symptoms. — Onset is slow or sudden. Begins with a 
numbness and tingling sensation in the area of distribution 
of the nerve. This is soon followed by occasional neuralgic 
pains and a dull, boring, tingling pain, increased by motion 
and pressure. Slight fever may develop in a few days, and 
continue for an indefinite period. Painful, spasmodic con- 
tractions of the muscles supplied by the affected nerves may 
occur; muscular power is diminished, and, in prolonged or 
chronic cases, may be entirely lost (paresis). In the super- 
ficial nerves there is a glossy redness along their course ; the 
nerve is prominent and swollen like a hard cord, and small 
vesicles form over its course and area of distribution . As 
a late symptom, atrophy of the muscles results. 

Electrical Reactions. — Faradic irritability is rapidly dimin- 

365 



36G A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

ished and lost in abont two weeks. Galvanic irritability is 
first diminished, then greatly increased, and remains so for a 
long time before it is finally lost (reaction of degeneration). 

Pathology. — Inflammation of the trne nerve structure is 
rarely well marked, for the nerves are not very vascular. It 
most commonly involves the sheaths of the nerves and inter- 
cellular structures ; causes proliferation of cells and exudation 
of leucocytes; gives rise to new inflammatory tissue which 
presses on the nerve structure, and causes its atrophy and 
destruction. By this pressure and destruction of nerve sub- 
stance, nervous impressions are improperly conveyed and de- 
layed by broken axis-cylinders and atrophied nerve-cells — 
hence a diminution and loss of sensory and motor impulses. 
As in other inflammatory affections, it extends along the 
nerve toward the central structures, and ultimately involves 
them (neuritis ascendens) ; or extends to the peripheral fila- 
ments (neuritis descendens). In chronic cases, nothing may 
remain of the original nerve but a fibrous cord, with here and 
there a few degenerated and atrophied nerve-cells. 

Neuritis varies in character according to the nerves in- 
volved, each separate nerve presenting its own characteristic 
symptoms. In the encephalic nerves there may be a loss of 
sight, smell, taste, and motion, or permanent loss of physio- 
logical action of the parts involved. 

Prognosis. — Traumatic and acute cases generally termi- 
nate favorably in one to eight weeks. Permanent paralysis 
may result. Prognosis should always be guarded. 

Treatment. — Bemove cause if possible. Put the parts at 
absolute rest, with bandages and splints if necessary. Hot 
applications along the affected nerve are most desirable ; cold 
may be more efficient and soothing in certain traumatic cases. 
If pain is very severe, give hypodermic of morphina. Establish 
free action of the emunctories by cathartics and diaphoretics j 



DISEASES OF THE NERVES. 367 

give light, nutritious diet. Local blood-letting may be very 
efficient. When cases do not respond to this method ; apply 
isolated blisters, sinapisms, or liniments at different points 
along the nerve-trunk over the seat of pain. Avoid electricity 
during the acute stages. 

Chronic neuritis requires alteratives and absorbents — full 
doses of iodides and mercury; counter-irritation and galva- 
nism. Strong currents must not be used except in prolonged 
chronic cases. Place the anode over the tender spot and 
move the kathode along the nerve for ten or twenty minutes. 



MULTIPLE NEURITIS. 

Synonyms. — Polyneuritis; disseminated neuritis; periph- 
eral neuritis. 

Definition. — A disease in which a number of nerves be- 
come inflamed at the same time, recognized by high fever, 
general aggravation of all symptoms of simple neuritis in the 
extremities, and is usually symmetrical. 

Etiology. — Most common in middle life from alcoholism 
lead-poisoning and toxic poisons ; syphilis ; specific diseases 
eruptive diseases ; tuberculosis ; rheumatism ; gout ; leprosy 
and septic infection. It may occur without any perceptible 
cause. Often follows or complicates epidemic meningitis. 

Symptoms — Begins with a numbness, slight tingling and 
pricking sensations in the extremities, increased by pressure 
and motion. Numbness soon becomes prouounced in the 
fingers and toes ; muscular action is weak. Severe paroxys- 
mal muscular cramps occur at intervals. Walking is very 
painful, unsteady, and, in some bad cases, impossible. The 
floor feels soft and yielding. Pulse is quick and excited; 
temperature may run to 105° F. in the early stages of acute 



368 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

eases. Paralysis extends from the periphery toward the cen- 
ter ; extensor muscles are more affected than the flexors ; lar- 
yngeal paralysis ; loss of reflexes ; muscular atrophy ; reaction 
of degeneration. There is tenderness, redness, and swelling 
along the course of the nerves, and often a vesicular eruption. 
Trophic changes are marked; bed-sores common; arthritis 
and fixation of the joints ; gradual affection of the mind, de- 
lirium, and general incoordination may complicate. 

Prognosis. — It is a very slow, tedious disease, prone to 
frequent relapses, and often terminates fatally during its early 
stages, from involvement of the diaphragm, heart, and respir- 
atory muscles. Alcoholic cases are unfavorable. Partial or 
complete recovery may occur in two to twelve months. 

Treatment. — Treat on the same general principle as in 
simple neuritis, directing remedies toward the cause. Alco- 
hol must be avoided. Narcotics may be necessary to control 
severe pain. During convalescence, give most nutritious, 
albuminous diet, and tonics suitable to each individual case. 



SCIATICA. 

Definition. — An inflammatory affection of the great sciatic 
nerve-trunk or its surrounding structures, recognized by ex- 
treme neuralgic pain along its course and distribution, and 
accompanied by slight constitutional symptoms. 

Etiology. — Exposure to cold and damp ; acute rheumatism ; 
direct injury ; extension from other parts ; pressure on the 
sciatic nerve by tumors, cicatrices, and adhesions; predispo- 
sition by heredity. More common in men. 

Symptoms. — Begins with a stiff, tired feeling in the back, 
hip, and leg on one side (both sides may be affected), followed 
by a numb, pricking, tingling pain along the sciatic nerve. 



DISEASES OF THE NERVES. 369 

Pain increases, is dull, boring, and aching, and every effort 
to move causes sharp, neuralgic pains, most marked in the 
hip, back of the thigh, and knee. Leg is flexed on the 
abdomen — this is the most comfortable position to them. 
Tenderness exists along the sciatic nerve, most marked at 
the back of the trochanter, popliteal space, side of the leg, 
and foot. 

There may be slight fever ; irritability ; constipation ; and 
anorexia. Electrical excitability is not materially changed. 
In long-continued cases there are atrophy of the muscles, pa- 
ralysis, reaction of degeneration, and trophic changes. 

Pathology. — Sciatica is not neuralgic in origin, but has the 
pathological lesions of neuritis or perineuritis. Adhesions 
form between the nerve trunk and sheath in very acute and 
chronic cases, producing pain and interference in the motion 
of the parts. Atrophy of the nerve- tissue occurs in prolonged 
cases. 

Diagnosis. — Neuralgia has tender points only ; sharp, shoot- 
ing pains ; very slight anaesthesia j no paralysis ; no atrophy 
of the muscles ; more paroxysmal in character ; electrical re- 
actions not diminished ; no fever. 

Myalgia or muscular rheumatism has no tender points ; is 
confined to a group of muscles; has no lancinating pains; 
is not greatly increased by motion; is relieved some by 
pressure. 

Prognosis. — Very favorable in acute cases. Chronic cases 
are obstinate, easily aggravated, and prone to relapses. 

Treatment. — Acute Sciatica. — Rest in bed in recumbent 
position, with the leg slightly flexed and supported by pil- 
lows. If pain is severe, administer a hypodermic of morphina 
and atropina, but do not repeat it. Chloroform, injected 
deeply over the sciatic nerve, is very efficient for pain. Hot 
applications, sinapisms, and blisters over the sacro-sciatic 



370 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

region. Begin treatment with a free saline cathartic, and 
follow with : 

ft 

Ext. cascarae sagradae flnidi f 3 v. 

Sodii salicylatis f 1 j. 

Aquae aurantii flor q. s. ad. f 3 iv. 

M. Signa. One teaspoonfnl every fonr or six hours. 

Full doses of acetanilide, phenacetin, and salicylates give 
temporary relief. 

When acute symptoms subside, and it tends to become 
chronic, administer colchieum, iodides, or mercury for a long 
period. Nerve-stretching, by forced flexion of the leg on 
the abdomen, will often break adhesions. Galvanism. Acu- 
puncture of the nerve at the sacro-sciatic foramen is practiced 
by some. 

FACIAL PARALYSIS. 

Synonym. — Bell's palsy. 

Definition. — A partial or complete loss of power of motion 
in the voluntary muscles of one side of the face which are 
supplied by the facial nerve (seventh cranial or portio dura 
nerve). 

Etiology. — Pressure of tumors on the nerve-trunk at the 
base of the brain j extension of inflammation from meningitis, 
causing neuritis or perineuritis j injury to the petrous part of 
the temporal bone, through which the nerve passes ; exposure 
to cold and wet. Secondary to certain acute diseases — rheu- 
matism, diphtheria, and syphilis. 

Symptoms. — Onset is sudden or slow, with a feeling of 
numbness, tingling, or pricking on the affected side ; facial 
muscles feel weak and drawn, and cannot be used freely. 
Complete loss of muscular power on the affected side soon 



DISEASES OF THE NERVES. 371 

follows, and the face assumes a typical appearance, with an 
entire lack of expression on the one side. Mouth cannot be 
properly closed, and the corner droops. 

Eyelids are relaxed, half closed; epiphora; and dryness of 
the cornea. The whole face appears drawn toward the un- 
affected side ; tongue is protruded to one side ; deglutition is 
often impaired j tinnitus aurium ; reflexes abolished. Electri- 
cal reactions: faradic excitability is soon lost; galvanic ex- 
citability is first increased, then diminished, and finally lost 
(reaction of degeneration). 

Prognosis. — Uncomplicated acute attacks recover in a few 
days or several weeks. Chronic cases depend upon central 
or structural lesions, and are unfavorable as to cure. 

Treatment. — Acute cases require rest in bed; free diapho- 
resis ; blisters, leeches, or hot applications over the mastoid 
process of the temporal bone and in front of the ear. Aconite 
and belladonna to relieve over-active circulation. Treat rheu- 
matic troubles as indicated. 

Chronic cases do best under the use of alteratives, hydrar- 
gyrum, and iodides. Galvanism is indicated when all acute 
symptoms have subsided. Massage may prove beneficial. 
Good, nutritious diet. 



DISEASES OF THE SPINAL CORD AND ITS 

MEMBRANES. 

SPINAL MENINGITIS. 

Varieties. — (1) Acute spinal meningitis or acute lepto- 
meningitis spinalis ; (2) chronic spinal meningitis or chronic 
leptomeningitis spinalis ; (3) pachymeningitis externa and in- 
terna. 

(1) ACUTE SPINAL MENINGITIS. 

Definition. — Acute spinal or leptomeningitis is an acute in- 
flammation of the pia mater and arachnoid, recognized by 
pains in the back, motor and sensory disturbances of the 
nerves involved. 

Etiology. — Exposure to cold and dampness; traumatism; 
rheumatism ; acute diseases ; extension from other parts. It 
is associated with acute, epidemic cerebro-spinal meningitis. 

Symptoms. — Onset may be sudden, with a chill or rigor, or 
may begin slowly with rise of temperature ; localized or gen- 
eral severe pain along the spinal column, which is increased 
by motion, deep pressure, and percussion. Sharp, shooting, 
tingling pains are reflected along the nerves arising from the 
affected area, and that portion of the skin which is supplied 
by them is hyperaesthetic. Violent muscular spasms may oc- 
cur, causing opisthotonos, emprosthotonos, pleurosthotonos, 
or orthotonus. 

372 



DISEASES OF THE SPEn t AL CORD AND ITS MEMBRANES. 373 

Reflexes are increased. Constipation ; occasional retention 
of urine ; a girdle sensation aronnd the body. On the second 
to fourth day symptoms of pain lessen, and are replaced by 
anaesthesia, paralysis, and diminished or abolished reflexes. 
Galvanic and faradic reactions, although increased at first, 
are soon diminished or lost. Symptoms will vary according 
to the parts affected. 

Pathology. — At first the pia mater and arachnoid are con- 
gested and red, bnt soon become inflamed, swollen, and cov- 
ered with an opaqne exudation which may become purulent. 
Adhesions form between the membranes, cord, and nerve- 
trunks. Swelling and inflammatory tissue cause pressure 
on the spinal cord and nerve-trunks, producing pain and all 
sensory and motor symptoms. The cord and nerves soon be- 
come inflamed, and the inflammation may spread to 'the cere- 
bral meninges and nerve-sheaths. 



Diagnosis. 



Myelitis. 



Onset usually very slow. 

Fever is slight, not typical. 

Pains and muscular spasms not de- 
fined. 

Sudden, complete paralysis and 
anaesthesia. 

Pains little influenced by pressure 
and motion. 

Cutaneous and muscular hyperes- 
thesia absent. 

Convalescence is very slow. 

Complications and sequelae marked. 

Obstinate bed-sores ; alkaline urine 
and cystic troubles. 



Acute Meningitis. 



Onset usually rapid. 

Fever is high and. persistent. 

Pains and muscular spasms well 
denned. 

Paralysis and anaesthesia are early 
symptoms, but not complete un- 
til late. 

Pains increased by pressure and 
motion. 

Cutaneous and muscular hyperaes- 
thesia well marked. 

Convalescence more rapid. 
No marked complications and se- 
quelae. 

No obstinate bed-sores ; cystic com- 
plications not marked. 



Prognosis. — Must always be guarded. Greatest danger 
lies in extension of inflammation to the centers of respiration 



374 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

and the heart. Recovery is usually accompanied by paraly- 
sis, partial or complete. Convalescence is slow. 

Treatment. — Absolute rest in bed, lying on the side or 
stomach. Wet or dry cups over the affected area of the spine ; 
applications of cracked ice. Administer a free saline cathar- 
tic and endeavor to establish diaphoresis and diuresis. Diet 
of beef -extracts, milk, farinaceous foods, toasted stale bread, 
and crackers. Avoid alcoholic stimulants and stimulating 
diet. If pains are very severe, administer morphina hypo- 
dermically, or give the bromides, acetanilide, or phenacetin. 
When the acute stage has subsided, administer mercury and 
iodides, with counter-irritation, galvanism, and massage. 
Stimulate as necessary. 

(2) CHRONIC SPINAL MENINGITIS. 

Etiology. — Acute inflammation may become chronic ; it 
may pursue a chronic course from the first, from syphilis, ex- 
posure, traumatism, chronic myelitis, and acute or chronic 
diseases. 

Symptoms. — No fever ; muscular spasms and rigidity come 
on slowly, and are not as well marked as in the acute ; local- 
ized and usually not general ; paralysis comes rather early. 
Other symptoms are similar to the acute form. 

Pathology — Pia mater and arachnoid are thickened and 
filled with new fibrous tissue and inflammatory products. 
Adhesions between the membrane and cord are numerous and 
well defined. Pressure upon the nerve-trunks and spinal cord 
produces atrophy and inflammation of their structures, fre- 
quently causing myelitis or neuritis. 

Prognosis. — Complete recovery is rare. It is obstinate to 
treat, and results are obtained slowly. Relapses are common. 
Localized permanent paralyses. 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 375 

Treatment. — Causal if possible. Counter-irritation over 
the spine, in the form of blisters and sinapisms. Cups and 
leeches frequently applied. Full doses of the iodides and 
mercury. Attend closely to all physiological functions — pre- 
vent retention of urine and obstinate constipation. Galva- 
nism and massage. Symptomatic treatment. 

(3) PACHYMENINGITIS SPINALIS. 

Description. — Pachymeningitis or inflammation of the dura 
mater is acute or chronic, external or internal. It is caused 
by an extension of inflammation from spinal caries, cancers, 
ulcers, and wounds j alcoholism and traumatism. The symp- 
toms are similar to those of acute and chronic leptomeningitis. 
In external pachymeningitis the external surface of the dura 
mater is thickened, infiltrated, and may be covered with a 
layer of creamy pus. 

Internal pachymeningitis affects principally the cervical re- 
gion and involves the brachial plexus of nerves. The internal 
surface of the dura mater is thickened, infiltrated, red, and 
may be covered with a diffuse hemorrhage. The nerve-roots 
are compressed. Acute cases are moderately favorable, and 
the chronic will depend on the cause. 

Treatment. — Treat as acute and chronic leptomeningitis. 
Remove every possible cause, such as carious bone, ulcers, and 
tumors. Evacuate pockets of pus promptly. Sustaining, nu- 
tritious diet and rest. 

ACUTE MYELITIS. 

Synonym. — Acute inflammation of the spinal cord. 
Etiology. — Exposure to cold ; shock ; traumatism ; general 
diseases j syphilis j compression; extension from other parts; 



376 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

and great functional activity. More common in men and 
during young adult life. 

Symptoms. — Onset may be sudden, with a chill, followed 
by a temperature of 102° to 104° F., and rapid pulse ; or it 
may begin slowly with sharp, shooting, darting pains in one 
or more parts of the body, varying with the nerve-roots 
affected, together with a numb, tingling, jagging feeling. 
Parts soon become anaesthetic; girdle sensations about the 
chest or abdomen. Paraplegia develops suddenly or slowly in 
a few hours or several days ; control of bladder and rectum 
soon lost j reflexes abolished ; reaction of degeneration at first, 
but all electrical reaction is soon lost; dyspnoea; gastrointes- 
tinal irritability ; priapism • urine alkaline ; occasional muscu- 
lar cramps ; trophic changes ; and obstinate bed-sores. Symp- 
toms vary with the part of the cord affected. 

Pathology. — Inflammation of the structure of the spinal 
cord is diffuse or focal. Diffuse myelitis involves large areas 
of the cord, and is very rare. Focal myelitis is confined to 
small areas, and is the most common form. The affected part 
of the cord is enlarged and softened. On section, the small 
capillary vessels are congested and prominent ; gray matter 
is quite dark. Microscopically, the nerve-fibers are broken 
up ; axis cylinders are enlarged ; nerve-cells are degenerated 
and destroyed ; new fibrous tissue is formed, and a large 
amount of granular matter is present. The spinal mem- 
branes are usually congested and involved. When cases be- 
come chronic, a distinct condition of sclerosis exists. 

Diagnosis. — See Meningitis, page 373. 

Prognosis. — Very grave. Death is caused slowly or sud- 
denly by paralysis of the muscles of respiration or of the heart ; 
general exhaustion ; cystitis and suppression of urine ; pyae- 
mia ; and intercurrent diseases. Complete recovery is rare, 
as some complications and sequelae almost invariably remain, 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 377 

Treatment. — Rest on a soft, downy mattress or water-bed 
to prevent bed-sores. Dry or wet cups, blisters, sinapisms, 
poultices, or cracked ice, as indicated by eacli case. When 
dne to cold, give free saline purge, diuretics, and diaphoretics 
during first stage only. Aconite, veratrum, acetanilide, phe- 
nacetin, or quinine may be beneficial if used early. Watch, the 
bladder closely to prevent retention of urine. Full doses of 
iodides and mercury may be beneficial when the most marked 
acute symptoms subside. Treat all complications and follow 
general rules given for meningitis. 



POLIOMYELITIS ANTERIOR ACUTA. 

Synonyms. — Anterior cornual myelitis ; acute spinal pa- 
ralysis ; atrophic spinal paralysis ; essential paralysis of chil- 
"dren. 

Etiology. — Exposure to cold; dentition; spiual injuries; 
acute diseases ; rheumatism ; and exanthemata. Most com- 
mon among children before the tenth year, but may occur in 
adults, when it is known as acute spinal paralysis of adults. 

Symptoms. — Onset is sudden, with a chill, rigor, or convul- 
sion, followed by moderate fever, which persists about one 
week. Occasional sensations of tingling and formication in 
the members supplied by the affected nerves. In a few days 
the power in one or more members is diminished and finally 
lost. Paralysis may involve both arms and legs. One pecul- 
iar characteristic of the disease is that one muscle or group 
of muscles may be paralyzed while the others are not affected. 
Those involved degenerate, atrophy, and show the reaction 
of degeneration ; reflexes are also lost. The heart, muscles 
of respiration, bladder, and rectum are affected. Paralysis 
manifests itself in one group and rarely spreads to others. 



378 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

The affected member is cold ; circulation is poor ; and growth 
retarded. Sensation remains unchanged. 

Pathology. — The pathological lesion is an acute inflamma- 
tion of the anterior cornu of the gray matter of the spinal 
cord. At first there is congestion, followed by true inflam- 
mation, formation of new connective tissue, transmigration of 
leucocytes, destruction and atrophy of motor nerve-cells and 
axis cylinders leading from them. Inflammation and degen- 
eration extend along the motor-roots of the nerves leading 
from the affected area. An entire absence of motor nerve- 
cells is found in prolonged cases. Affected muscles are in a 
state of fatty and granular degeneration and atrophied. 

Prognosis. — Rarely fatal per se, unless the lesion exists in 
the medulla. Death usually follows complications. Complete 
recovery is very rare. 

Treatment. — Complete rest in bed until acute symptoms 
subside. Give aconite, liq. ammonii acetatis, or potassii cit- 
ras for fever. Compresses of ice to the spine. Potassium 
iodide or syr. acidi hydriodici, every three or four hours, with 
infusion of digitalis. Institute best hygiene and feed regu- 
larly at intervals of four hours. 

When acute symptoms subside, use weak galvanism, mas- 
sage to the affected muscles, and administer strychnina in full 
doses. Use any mechanical devices to support and preserve 
the impaired members. 

PARALYSIS ASCENDENS ACUTA. 

Synonym. — Landry's palsy. 

Description. — A disease described by Landry in 1859, in 
which paralysis begins in the lower extremities, rapidly ex- 
tends upward, produces death, and is not characterized by 
any distinct pathological lesion. It is more common among 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 379 

men, and follows exposure to cold, acute diseases, and syphilis. 
It is heralded by formication, numbness, pricking pains in the 
legs, and a bilateral loss of power in those members. Paraly- 
sis soon becomes comj^lete. In one or two days the muscles 
of the thighs, hips, back, and abdomen are paralyzed ; power 
of rectum and bladder are unimpaired. The paralysis ex- 
tends upward, finally involves the diaphragm and respira- 
tory muscles, and causes death by asphyxia. Occasionally 
the cranial nerves are involved before death. Sensation is 
not lost ; muscles do not atrophy ; little or no fever ; electri- 
cal reactions not affected; reflexes are diminished or lost. 
Recovery is rare ; death may ensue in twenty-four hours to a 
month. No satisfactory method of treatment is known, but 
it is wise to follow the general rules given for acute myelitis. 

SPINAL SCLEROSIS. 

Definition. — An overgrowth of the interstitial connective 
tissue of the spinal cord, accompanied by degeneration and 
atrophy of the nerve-cells ; dependent upon inflammation and 
manifesting itself in many different symptomatic forms, viz. : 
(1) antero-lateral spinal sclerosis ; (2) posterior spinal sclerosis ; 
(3) multiple spinal sclerosis ; (4) hereditary ataxia. 

Etiology. — Follows acute myelitis or spinal meningitis ; 
direct injury ; acute diseases ; syphilis ; mineral poisons ; ex- 
posure ; alcoholism ; venereal excesses. A disease most com- 
mon among men from thirty to fifty years of age. Is fre- 
quently hereditary. 

(1) ANTERO-LATERAL SPINAL SCLEROSIS. 

Synonyms. — Duchenne's disease ; chronic anterior polio- 
myelitis; chronic diffused atrophic paralysis (Fagge). 



380 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Symptoms. — Lower extremities become weak • patient walks 
on tiptoe with a waddling gait and a tendency to fall forward. 
Complete paralysis soon develops, and may spread to the mus- 
cles of the back and arms. Muscles are flabby ; waste rapidly ; 
give reaction of degeneration ; sensation is not lost ; bladder 
and rectum not affected; absence of bed-sores; joints become 
stiff. Pains in the back and limbs of a tingling or dull char- 
acter ; headache ; slight fever ; muscular stiffness and occa- 
sional cramps, which precede the actual paralysis. It either 
pursues a chronic course, gradually becoming worse, involving 
the upper extremities, or gradually improves until partial or 
complete return of power ensues. Prognosis is uncertain; 
may last four or five years before fatal termination. 

Pathology. — In the anterior cornu, the multipolar gray 
nerve-cells and axis-cylinders are degenerated, atrophied, and 
destroyed ; considerable granular matter is present ; prolifer- 
ated cells and general sclerotic condition of the anterior and 
lateral columns of the cord. Motor nerve-roots are atrophied. 
This condition spreads from below upward. 

(2) POSTERIOR SPINAL SCLEROSIS. 

Synonyms. — Locomotor ataxia ; tabes dorsalis ; locomotor 
ataxy. 

Symptoms. — Onset is very slow, and among the first symp- 
toms noted are sharp, shooting, neuralgic pains, which occur in 
the lower extremities at irregular periods. Pain may con- 
tinue for a few seconds or intermit and remit with more or 
less severity for several hours Reflexes are diminished and 
finally abolished. Sensation is soon impaired ; cannot distin- 
guish when the feet are set firmly on any object ; sensation is 
that of walking on velvet or some very elastic substance ; a 
feeling very similar to that produced when the " foot is asleep." 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 381 

Sensory impressions are delayed several seconds or minutes after 
the impression has been made. 

Ocular symptoms appear in the form of strabismus, diplopia, 
ptosis, squinting, and the Argyll-Robertson pupil — a myotic 
pupil which responds to accommodative effort, but not to 
light. Powers of coordination are diminished; gait is un- 
certain, with a tendency to fall when eyes are closed or feet 
closely approximated ; cannot walk in a straight line ; cannot 
turn around without help and are unable to stop themselves 
voluntarily. As disease advances, the legs are thrown wildly 
about when walking and the heels come down on the floor 
very hard. Electrical reactions are normal ; muscles do not 
atrophy, except from disuse ; muscular power is retained and 
sometimes increased. 

Girdle pains ; sensory changes — anaesthesia, analgesia, prick- 
ing sensations ; and increased susceptibility to heat and cold. 
Bladder is irritable and power soon lost ; sexual organs greatly 
excited at first, but impotence results. Gastric crises are sharp 
pains in the stomach and back, and obstinate vomiting. Crises 
may occur in any of the viscera. 

Trophic Changes. — Brittleness of the bones; changes in 
joints ; falling of the hair and nails ; blisters ; localized sweat- 
ing. Among complications and sequelae are optic neuritis 
and loss of sight ; deafness ; paralysis ; severe headaches ; apo- 
plexy ; epilepsy ; most obstinate bed-sores ; cystitis ; pyaemia ; 
and general paralysis of the insane. Absolute recovery is 
rare ; may persist for many years and terminate in death from 
one of the crises or complications. 

Pathology. — Posterior columns of the spinal cord are scle- 
rosed, most marked in the lumbar region. Posterior cornu of 
gray matter is more or less involved, showing degeneration 
and atrophy of the nerve-cells and axis-cylinders ; meninges 
over affected part of cord are frequently involved; sensory 



382 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

nerve-roots are atrophied. In the bones there is an increase 
of mineral salts, rendering them brittle. Pains are due to in- 
volvement of sensory nerve-roots. Impression made on the 
extremities is carried by the sensory nerves until the diseased 
parts are reached, when it is either stopped or reaches the 
nerve-centers through circuitous routes, thus producing de- 
layed sensation. Incoordination is dependent upon impaired 
sensory action. 

(3) MULTIPLE SPINAL SCLEROSIS. 

Synonyms. — Disseminated sclerosis ; insular sclerosis ; cere- 
brospinal sclerosis ; Charcot's disease. 

Symptoms. — Onset is usually slow, but may be sudden, with 
weakness and trembling in the arms or legs, and loss of mus- 
cular control. Tremor is very characteristic ; is absent dur- 
ing rest and sleep, and present only during voluntary efforts. 
When the arm is moved, it vibrates with a quick, jerking 
motion from side to side, increasing with the effort. This 
vibratory movement or tremor is so pronounced that it is im- 
possible for the patient to lift a glass of water without spilling 
it. Not ouly are the arms affected, but the head nods to and 
fro, the body sways from side to side, and the legs are very 
unsteady. The eyeballs oscillate (nystagmus) from side to side 
whenever an effort is made to concentrate them upon any 
object. Speech is spasmodic, scanning, staccato in character, 
and slow, with distinct articulation of every syllable. Sensa- 
tion is altered ; there is numbness, formication, tingling, and, 
occasionally, complete anaesthesia. Muscles atrophy; electri- 
cal reactions are diminished late ; headache ; diminution of 
vision ; delusions and general paralysis of the insane. 

Pathology. — Small isolated and disseminated spots of 
chronic inflammation and sclerosis are found in the brain, 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 383 

medulla, and spinal cord. These spots are darker than the 
surrounding structure, and harder. Sclerosis may extend to 
the nerve-roots and produce neuritis. Nerve-cells and axis 
cylinders are degenerated and destroyed in the sclerosed 
areas ; vessel-walls are thickened and in a state of fatty de- 
generation. 

Diagnosis. — See table, page 361. 

Prognosis. — Disease may run for twenty years. Death 
may ensue from sudden apoplectic attacks. Complete paraly- 
sis and inability to help themselves may last for years. These 
patients are very susceptible to acute diseases, which usually 
prove fatal. 

(4) HEREDITARY ATAXIA. 

Synonym. — Friedreich's disease. 

Description. — A disease transmitted by heredity to one or 
more members of one family. It is a sclerosis of the lateral 
and posterior columns of the spinal cord ; begins in early life, 
about puberty. There is a lack of coordination in the legs ; 
movements are uncertain and jerky ; patellar and plantar re- 
flexes are diminished early ; sensation is not often impaired at 
first 5 anaesthesia may develop later ; absence of sharp pains ; 
speech is uncertain, hesitating, and interrupted ; nystagmus 
produced by lateral motion of the eyes, but checked when 
they are fixed on any object. Arms, head, and neck are soon 
involved. Absence of complete paralysis, optic neuritis, crises, 
trophic disorders, and mental changes. Disease may continue 
many years, and death ensue from complications. Recovery 
is rare ; usually get worse. 

Treatment. — The treatment of all forms of spinal sclerosis 
is similar and rather unsatisfactory. Diet, hygiene, and exer- 
cise must be regulated according to the needs of each case. 
Iodides, mercury, double chloride of gold and sodium, zinc 



384 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

salts, phosphorus, silver salts, arsenic, strychnine, belladonna, 
ergot, iron, and numerous other remedies are recommended 
and given in doses which vary with the therapeutical and 
physiological indications. Counter-irritation over the spine ; 
galvanism and faradism — the former producing best results. 

For the pains of locomotor ataxia, morphina hypodermically. 
Cannabis Indica, gr. |-, every three or four hours ; phenacetin 
or acetanilide, gr. x-xv, every three hours. Always watch 
for retention of urine. Charcot's method of suspension of the 
body by the head and shoulders is supposed to relieve spinal 
tension and some unfavorable symptoms of locomotor ataxia. 
It is a dangerous method ; must be very cautiously used ; 
must not be practiced longer than twenty seconds to three 
minutes, varying with each case, and must be followed by 
absolute rest in the recumbent position. In fact, all forms 
of i treatment resolve themselves into treatment of symptoms 
and complications. 



DISEASES OF THE BRAIN AND MEMBRANES. 



ACUTE CEREBRAL MENINGITIS. 

Etiology. — Traumatism • exposure to cold ; extension from 
other parts, as from the ear; exposure to the sun; alcohol- 
ism ; syphilis. Most common in young adults. 

Symptoms. — Prodromal. — For an uncertain period of time 
there is uneasiness, headache, nausea or vomiting, feverish - 
ness, tinnitus aurium, and giddiness. 

First Stage. — Onset generally begins with a chill, which is 
soon followed by high fever, 104° F. Headache, tinnitus 
aurium, and vertigo increased; conjunctivae are congested; 
face is red and hot ; persistent nausea and vomiting ; pulse is 
tense and rapid; photophobia; pupils often contracted; con- 
stipation. Delirium and convulsions follow. Hyperesthesia ; 
muscular twitchings and spasms, often amounting to opistho- 
tonos. 

Second Stage. — In one to four days delirium and muscular 
spasms subside and patient becomes comatose ; extremities are 
cold ; pupils dilated ; pulse feeble and slow ; urine and f a?ces 
passed involuntarily ; fever is diminished ; paralysis of one or 
more groups of muscles ; death from deep coma or collapse. 
If recovery ensues, there is severe headache, which persists 
for many months or years. 

Pathology. — An acute inflammation of the cerebral pia 
mater and arachnoid membranes. A serous effusion, often 
becoming purulent, is found in the subarachnoid space and 

385 



386 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

ventricles of the brain. Meningitis may be general; may 
affect the convexity of the brain or its base (basilar meningitis). 
Owing to pressure of the exudation and inflammatory products, 
the brain substance is impinged upon, flattened, and, not in- 
frequently, atrophied, destroyed, ecchymotic, or filled with 
small abscesses. 

Prognosis. — Most cases are fatal. Headaches, defects of 
vision, blindness, deafness, epilepsy, or muscular paralysis may 
follow cases of recovery. 

Treatment. — Put patient in a dark, cool room, and keep as 
quiet as possible. Cold water, coils, compresses of cracked ice 
should be applied constantly, and the head slightly elevated 
above the level of the body. Administer a free drastic or 
saline cathartic at the onset. Venesection may be necessary 
to relieve severe congestive symptoms. Aconite or veratrum 
to reduce active circulation. Large doses of bromides, acet- 
anilide, or phenacetin will give partial relief to headache, but 
are liable to depress the heart. Ergot is of doubtful utility. 
Give a diet of milk and farinaceous foods. 

When acute stage subsides, give stimulating diet and stimu- 
lants as indicated. Small doses of calomel or mercury pro- 
tiodide. Occasional blisters to the base of the skull may be 
beneficial. Surgical operations have recently been advocated 
for removal of large intracranial effusions. 

TUBERCULAR MENINGITIS. 

Synonyms. — Acute hydrocephalus; basilar meningitis. 

Etiology. — A disease found most frequently in youug 
male children who inherit or show a predisposition to the 
tubercular diathesis. It may occur in adults and is brought 
into activity by acute diseases, hip-joint disease, or diseases 
of the middle ear. 



DISEASES OP THE BRAIN AND MEMBRANES. 387 

Symptoms. — Child may be drooping, indifferent, uneasy, 
fretful, constipated, and generally debilitated for weeks or 
months before the onset. Onset begins with slight headache, 
which soon assumes a severe, constant type, and causes the 
child to cry out and scream with the pain ; nausea and vomit- 
ing, followed by convulsions. Slight fever develops ; pulse is 
quick ; great sensitiveness to light and sound. Patient lies in 
bed all the time and does not wish to be disturbed. There is 
squinting and diplopia. 

In a few days vomiting ceases, but headache persists or in- 
creases ; delirium and drowsiness ; head, neck, and back are 
drawn into a condition of opisthotonos ; pulse is slow and ir- 
regular ; high temperature ; face flushed ; vaso-motor disturb- 
ance, shown by a persistent redness of the skin after slight 
pressure on it; bowels constipated; loss of appetite; optic 
neuritis. 

Drowsiness and all symptoms increase ; Cheyne- Stokes breath- 
ing ; hyperpyrexia; local paralysis; unequal pupils; convul- 
sions; profound coma and death. The duration of the dis- 
ease, from time of onset to its termination, varies from two 
days to three weeks. 

Pathology. — Pia mater is the membrane involved, and is 
covered by an effusion of lymph of a clear, opaque or yellow 
color over its basilar portion, its prolongation into the fissures, 
and along the cerebral arteries. The upper portion of the 
pia mater over the hemispheres is almost entirely free from 
the exudation. All over the affected area are found miliary 
tubercles of a grayish color, some of which have caseated. 
The ventricles of the brain are filled with fluid — hence the 
term acute hydrocephalus. Tubercles are sometimes found in 
the spinal membranes, lungs, and other organs. 

Prognosis. — Most cases terminate fatally in two to four 
weeks. Death may occur in a very few days. 



388 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Treatment. — Entirely symptomatic. Treat as acute cere- 
bral meningitis (p. 386). 

CEREBRAL PACHYMENINGITIS. 

Description. — Inflammation of the dura mater covering the 
brain maybe external (pachymeningitis externa), from trauma- 
tism, extension from diseased bone, or disease of the middle 
ear ; or internal (pachymeningitis interna). Inflammation of the 
dura mater may be accompanied by hemorrhage — hence the 
name hcematoma of the dura mater, or meningitis interna licemor- 
rhagia. The latter condition may occur in old people from 
apoplexy, alcoholism, gout, and syphilis. The dura mater is 
soft and friable, but in chronic cases it is tough and fibrous. 

Symptoms. — Not constant. Headache ; photophobia • gid- 
diness; drowsiness, gradually assuming a type of coma; 
twitchings and convulsions of various muscles ; slow, irregu- 
lar pulse ; slight fever. Intellect, memory, and intelligence 
may be impaired. Diagnosis is never certain, and prognosis 
is unfavorable. 

Treatment. — Symptomatic and causal. 

HYDROCEPHALUS. 

Definition. — The presence of large quantities of fluid in 
the ventricles of the brain, the pia mater, arachnoid spaces. 
brain substance, or all. Most common in children, and mani- 
fests itself by varying nervous phenomena. 

Congenital or chronic hydrocephalus occurs as an external 
hydrocephalus when the effusion is in the pia mater, internal 
hydrocephalus when in the ventricles of the brain, and mixed 
hydrocephalus when in both. 

Acute or acquired hydrocephalus is dependent upon tubercu- 
lar meningitis, already described (p. 380). 



DISEASES OF THE BRAIN AND MEMBRANES. 389 

Etiology. — A disease of young children of tubercular and 
syphilitic extraction, in whom there is an arrest of cerebral 
development or intracranial irritation. 

Symptoms. — Congenital Hydrocephalus. — Gradual enlarge- 
ment of the head, and emaciation. Appetite is good ; general 
drowsiness and listlessness ; dullness of intellect and lack of 
the general brilliancy of most children. The head soon as- 
sumes a size entirely out of proportion to the child's body 5 
face is small and wrinkled ; head becomes too heavy and tends 
to sag. Voice is shrill and pitched in a high key. If case 
progresses, convulsions soon occur ; muscular power becomes 
deficient ; vision and other senses are often impaired or lost ; 
vomiting may complicate, and death ensue from convulsions, 
coma, or intercurrent diseases. In rare cases the fluid has 
been known to escape by rupture of the integument. Cases 
may be arrested in their course, but the general duration of 
life varies from one to ten years — one case running twenty- 
one years. 

Pathology. — The effusion, which is similar to the cerebro- 
spinal fluid, varies in amount from a few ounces to a quart ; 
is found in the ventricles of the brain, in the arachnoid spaces, 
in the substance of the pia mater, and, occasionally, in the 
brain substance itself. As the effusion accumulates, it presses 
against the brain and flattens it against the skull ; the bones 
of the skull are forced outward in the lines of least resistance, 
and in time become as thin as tissue-paper. The veins are 
prominent all over the head. Inflammatory changes may be 
present or absent. When the fluid is in the arachnoid spaces 
and not in the ventricles, pressure on the brain reduces it to 
a small, compact mass. 

Diagnosis. — Rachitis presents a skull which is compressed 
laterally and is quite long ; has a high, square forehead ; gen- 
eral symptoms of rickets. A hydrocephalic skull is rounded 



390 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

in ail directions ; prominent, overhanging forehead; promi- 
nent and divergent eyeballs. 

Treatment. — Surgical measures meet with most favor. As- 
piration of small amounts of the fluid from time to time, fol- 
lowed by adhesive strips or bandages to exert slight pressure. 
Mercury and the iodides. Nutritious diet of milk, animal- 
broths, whites of egg, beef preparations, and scraped beef. 
Observe general rules for treating persons with a tubercular 
or specific diathesis. 



CEREBRAL HYPEREMIA. 

Synonyms. — Congestion of the brain ; cerebral congestion. 

Definition. — An abnormal increase of the arterial or 
venous supply of blood to the brain, recognized by headache, 
giddiness, flushed face, and general nervous manifestations. 

Etiology. — Active or arterial hypercemia is caused by excess- 
ive action of the heart, as in violent exercise, or by hypertrophy 
of the left ventricle; injury to the head; apoplexy; plethora; 
insolation; alcoholism; mental over-activity or excitement; 
excesses ; anger ; obstruction to the circulation ; prolonged 
stooping or hanging with the head downward. 

Passive or venous hypercemia is caused by some obstruction 
to the return venous circulation. 

Symptoms. — Begins suddenly or gradually with a feeling 
of fullness and throbbing in the head, accompanied by dizzi- 
ness ; ringing in the ears ; " bleary vision " ; flashes of light in 
the eyes ; grea/t mental excitement ; inability to concentrate 
thoughts ; irritability ; slight delirium ; dyspnoea ; and a throb- 
bing or neuralgic headache. Carotids pulsate freely ; face is 
red and flushed ; conjunctivae are congested. In old persons 
these phenomena are often replaced by apoplectic symptoms. 



DISEASES OF THE BRAIN AND MEMBRANES. 391 

Attacks may be transitory in character ; may last one minute 
to several days, and often recur. 

Diagnosis. — Apoplexy. — Consciousness is lost entirely; 
paralysis is unilateral; symptoms prolonged; motion and 
sensation involved at the same time in same part. 

Embolism. — Sudden onset ; prolonged or permanent paraly- 
sis ; history of heart or arterial diseases. 

Treatment, — If due to an over-loaded stomach, administer 
an emetic. Give full doses of aconite or veratrum to control 
over-active circulation. Place patient in recumbent position, 
with head elevated ; apply cold to head, and put feet in hot 
mustard-water. Venesection may be indicated in plethoric 
persons and those predisposed to atheroma. A hypodermic 
injection of morphina and atrophia allays excitability. Give 
saline cathartics and calomel. Limit amount of liquids taken, 
and do not administer them hot. Let diet be a light, farina- 
ceous one. Treat symptoms and complications as they arise. 

Passive hyperemia is treated on the same general principles, 
taking care to give remedies for heart-troubles and to relieve 
local obstructions. 

CONCUSSION OF THE BRAIN. 

Description. — Concussion or violent shaking of the brain 
is caused by a direct blow upon the head ; or, indirectly, by a 
shock produced by falling from a height, but alighting on the 
feet. Symptoms will depend upon the shock produced. It 
may amount to a mere stunning or blunting of intellect for a 
few moments, together with slight nausea, yawning, and un- 
easiness. In severe cases, sensibility is lost ; pupils are con- 
tracted ; face is pale and cold ; pulse rapid, thready, and com- 
pressible ; nausea ; shallow respiration ; diarrhoea ; retention 
or involuntary passage of urine ; can be roused from the stupor 



392 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

only with difficulty. This stage may last for several hours, 
when they either die or show signs of reaction and restoration 
of functions. Inflammation of the meninges or brain may 
follow. 

Diagnosis. — Compression of the brain has complete insen- 
sibility ; pallor • stertorous respiration ; dilated pupils and fixed 
eyes ; pulse is full and slow ; bowels inactive j local paralysis. 

Treatment. — Remove all tight clothing- rub the body and 
extremities freely to restore circulation. Administer diffusible 
stimulants by the mouth, if they can swallow ; but if not, give 
strychnina or ammonia hypodermically. Small inhalations of 
ammonia often encourage restoration ; apply warmth to the 
feet and body. Cold should be applied to the head. When 
reaction is established, opium and sedatives may be indicated 
to avert inflammation. Patient should be cautioned to re- 
main in bed for several days or longer, until convalescence is 
fully established, as inflammatory symptoms are prone to fol- 
low for some time after reaction. 

CEREBRITIS. 

Description. — Inflammation of the structure of the brain 
may be acute or chronic, local or general. 

Acute cerebritis is caused by direct injury, embohsm, septi- 
caemia, pyaemia, or extension from other parts. That portion 
of the brain involved is soft and friable ; quite red in color 
from increased vascularity and hemorrhage, and is called red 
softening of the brain. The nerve-cells are degenerated. It 
begins with headache, vomiting, and slight fever. Convul- 
sions and delirium soon follow. It may begin suddenly like 
an apoplectic attack. Paralysis is limited and involves cer- 
tain groups of muscles. Aphasia may occur. Mind is never 
perfectly sound, and death follows. 



DISEASES OF THE BRAIN AND MEMBRANES. 393 

Chronic cerebritis is dependent on syphilis, embolism, cere- 
bral hemorrhage, prolonged mental work, insanity, and exten- 
sion from other parts. The affected area of the brain is soft, 
and creamy white or yellow in color, termed yellow softening 
of the brain. It manifests itself by a gradual failure of intel- 
lect ; dizziness ; hypergesthesia or ansesthesia ; general debility ; 
headache ; local paralysis ; senses may be diminished or lost. 
In one to three years, patient dies of debility or intercurrent 
affections. 

Treatment. — Little can be done in acute or chronic cere- 
britis except to treat symptoms, and upon the general plan of 
tonics and alteratives. Endeavor to nourish patients as much 
as possible. Stimulate as necessary. 

CEREBRAL HEMORRHAGE. 

Etiology. — Cerebral hemorrhage is most common in men 
who have passed forty. Secondary to atheroma, miliary cere- 
bral aneurysms, syphilis, gout, plethora, tuberculosis, various 
diatheses, Bright's disease of the kidneys. In many cases it 
is hereditary. 

Exciting causes are over-exertion, mental and physical ; in- 
temperance in diet and drink ; sudden or prolonged stooping ; 
may occur during rest or sleep, without any apparent exciting 
cause. 

Symptoms. — Apoplectic. — Apoplexy may begin suddenly or 
be preceded for a few hours or days by slight headache, un- 
easiness, giddiness, and numbness of the extremities. Onset 
is sudden, with rapid loss of consciousness ; patient falls sud- 
denly after some exertion or during rest. It may begin with 
very severe headache, faintness, impaired speech, paralysis, 
convulsions, followed by a gradual loss of consciousness until 
they become comatose and cannot be roused, 



394 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

Face is red and congested ; breathing is stertorous ; absence 
of superficial reflexes; pupils may be contracted, dilated, or 
uneven ; subnormal temperature ; rapid pulse ; profuse sweat- 
ing in some cases ; gradual cyanosis and death. On the other 
hand, they may remain comatose for several hours or days, 
and gradually regain consciousness. 

Hemiplegic. — When consciousness returns, temperature rises 
to 102° or 104° F., and one or more groups of muscles on the 
same side of the body are paralyzed, usually the muscles of 
an arm, leg, or both. Tongue is often protruded to one side, 
or corner of the mouth is drawn. These paralyses may re- 
cover entirely in a few weeks or months ; may recover par- 
tially ; or may be permanent. Muscles sometimes become rigid 
and cause permanent flexion of the fingers ; are slightly atro- 
phied, but retain their normal electrical reactions. 

Aphasic. — Aphasia is a complete or partial loss of power of 
speaking or understanding spoken or written language, caused 
by some central nerve-lesion. Aphasic symptoms vary in 
character. The mind may be as blank as that of a baby; 
they may be able to utter sounds, but not intelligent and ar- 
ticulate speech (aphemia)-, absolute loss of memory (amnesic 
aphasia). Some use wrong words to express their ideas. 
They may be able to speak intelligently, but cannot write 
(agraphia) or read. 

Pathology. — Arteries of the brain are found in a state of 
atheromatous degeneration, or their peripheral branches are 
filled with miliary aneurysms. Hemorrhage varies in amount, 
from a very slight effusion of blood, which presses on one 
part of the brain substance, to very profuse ones, which break 
down the brain and fill the ventricles, sulci, and fissures. Re- 
cent cases show a dark-red clot, old cases a dark-yellow clot, 
of disintegrated blood. When blood first escapes, it forms a 



DISEASES OF THE BRAIN AND MEMBRANES. 395 

clot which in time contracts, undergoes degeneration, and is 
partially or entirely absorbed. 

Hemiplegic, aphasic, and other symptoms will vary accord- 
ing to the nerve-centers involved, and the seat of hemorrhage 
can be determined during life by a knowledge of cerebral lo- 
calization of the functions. Hemorrhages are most common 
in the branches of the middle cerebral artery, in the optic 
thalamus and corpus striatum. Brain substance is degener- 
ated in the region of the clot. Hemiplegia is always on that 
side of the body opposite to the part of the brain affected — 
hemorrhage on the right side of the brain means paralysis on 
the left side of the body. 

Diagnosis. — Epilepsy. — Previous history ; sudden onset 
with epileptic cry ; frothing at the mouth ; grinding the teeth 
and biting the tongue; no hemiplegia; can be roused from 
stupor ; is a disease of young people ; no subnormal tempera- 
ture ; no characteristic breathing. 

Alcoholism. — Insensibility not complete ; no stertorous 
breathing ; pupils react to light ; pulse is rapid ; can be roused 
by stimulants ; absence of hemiplegia ; detection of alcohol in 
urine. 

Opium Narcosis. — Gradual onset ; pupils contracted to pin- 
points ; can be temporarily roused ; no hemiplegic symptoms ; 
slow pulse and respiration ; history of case ; uncertainty of age. 

Urcemic Coma. — History ; preceded or accompanied by con- 
vulsions ; albuminuria ; can often be roused temporarily ; no 
paralysis ; no congestive symptoms of face ; normal reflexes ; 
no secondary fever. 

Prognosis. — Favorable if consciousness and rise of tem- 
perature begin within twenty-four hours. Unfavorable as 
to life in irregular respiration, convulsions, vomiting, and pro- 
longed low temperature. One attack is commonly a forerun- 



396 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

ner of others which will ultimately result fatally. Recovery 
is prolonged, tedious, and always followed by one or more 
sequelae or complications. 

Treatment. — Whenever premonitory symptoms manifest 
themselves, patient should be put to bed at once ; cold applied 
to the head and heat to the extremities. Free saline or dras- 
tic cathartics should be administered until free action is ob- 
tained. Avoid hot, stimulating drinks. Aconite or vera- 
truni for over-active circulation. Venesection in full-blooded, 
plethoric persons. 

During the attack, cold should be applied to the head ; head 
must be elevated ; warmth to the body and extremities. When 
pulse is full and bounding, venesection may be advisable, or 
hypodermic administration of veratrum or aconite. If pulse 
is weak, unsteady, and compressible, give digitalis, ammonia, 
or- strychnina hypodermically. Attend carefully to bladder 
and prevent retention of urine. When consciousness begins 
to return and patient can swallow, establish free purgation, if 
patient is plethoric and not depressed. If weak and anaemic, 
give tonic medication and avoid purgatives. Do not allow 
the circulation to become very active nor fever to remain high 
for any long period. 

When all acute symptoms subside, alteratives and absorb- 
ents should be administered for weeks or months. Massage 
and electricity to the affected limbs. Great care must be ex- 
ercised in habits of physical and mental activity, hygiene, and 
diet, to prevent recurrence. 

CEREBRAL EMBOLISM AND THROMBOSIS. 

Definitions. — Cerebral embolism is the lodgment of an em- 
bolus (a blood-clot carried from some point in the circulation) 
in one of the cerebral vessels. 



DISEASES OF THE BRAIN AND MEMBRANES. 397 

Cerebral thrombosis is the gradual formation of a clot or 
thrombus in one of the cerebral vessels. 

Etiology. — Embolism is due to the formation of clots in 
valvular heart-diseases, thrombosis, and endocarditis, which 
become detached and are carried into the cerebral vessels by 
the circulation. 

Cerebral thrombosis is due to the formation of a clot on the 
roughened wall of a degenerated or atheromatous cerebral 
vessel. 

Symptoms. — Cerebral Embolism. — Onset is sudden, with 
vertigo and severe headache ; nausea and vomiting ; impair- 
ment of speech and hemiplegia. Symptoms often simulate 
those of cerebral hemorrhage, and begin suddenly with com- 
plete loss of consciousness. Death not infrequently occurs, 
but recovery soon ensues if collateral circulation is established. 

Cerebral thrombosis is preceded by headache, slight dizziness, 
and nausea j formication, numbness, and impaired motility in 
one half of the body j absent-minded j impairment of speech ; 
general anxiety, lasting from a few hours to several days, when 
patient is seized with symptoms similar to cerebral hemor- 
rhage. Recovery may ensue, or death from exhaustion, paral- 
ysis, septicaemia, or pyaemia — the latter if the thrombus is of 
septic origin. 

Pathology. — When an embolus or thrombus occludes a 
cerebral vessel there is anaemia and malnutrition of that part 
of the brain supplied by it, which results in softening of the 
brain. This means a destruction of a number of centers, with 
corresponding motor and sensory symptoms in the parts which 
they control. If collateral circulation is established early, 
complete recovery may be expected. 

Treatment. — Sustain with nourishing diet and stimulants. 
Avoid depressants and venesection. Treat diseases of heart 
as indicated. Ammonium carbonate, with iodides and mer- 



398 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

cury, seems to hasten absorption of clots. Treat as in the 
second and third stages of cerebral hemorrhage. 

CEREBRAL ABSCESS. 

Description. — Abscess of the brain is rarely primary, bnt is 
secondary to snppnration of the middle ear, scarlatina, necro- 
sis, diseases of the nose and frontal sinuses, syphilis, and pyae- 
mia. Abscesses may be single or multiple, and will vary in 
position according to cause ; are small, or one or two inches 
in diameter ; contain a greenish and, at times, a very offensive 
pus. 

Symptoms. — Vary according to size and location. Pain 
in the head is dull, throbbing, sharp, or neuralgic, and ex- 
acerbates at irregular intervals. Pyaemic symptoms of chills, 
rigors, fever, and profuse sweating. Vomiting and convul- 
sions ; optic neuritis ; alterations in mental faculties ; loss of 
flesh j motor and sensory paralyses, varying with the centers 
affected ; aphasia may be expected. Cerebral abscess may run 
a rapid course in a few weeks or may last for many months. 
Death is caused by debility, inanition, and paralysis of the 
various vital centers. Recovery may ensue, but the prognosis 
is always unfavorable. 

Treatment. — Symptomatic, palliative, and surgical. Ab- 
scess should be opened freely by trephining as soon as diag- 
nosed, for delays are unusually fatal. 

CEREBRAL TUMORS. 

Varieties. — Glioma is a tumor of neuroglia-cells, occur- 
ring in the substance of the brain and spinal cord, belonging 
to the variety of round-cell sarcoma; is the most common 



DISEASES OP THE BRAIN AND MEMBRANES. 399 

tumor found in the brain j is never encapsuled, and is very 
prone to hemorrhage. 

Sarcoma grows from the membranes or the bones of the 
cranium ; is either primary or secondary, single or multiple. 

Tubercle is either single, as a large tumor in the brain sub- 
stance or on the meninges ; or multiple, as in miliary cerebral 
tuberculosis. 

Gumma form on the membranes, inner surface of the cranial 
bones, and are caused by syphilis. 

Cysts may form from parasites and disintegrating tumors. 

Aneurysm may be single or multiple ; very small or large. 

Etiology. — Syphilis; tuberculosis; parasites; injury; athe- 
roma of the vessels ; cancer ; heredity. Cerebral tumors are 
most common in males. 

Symptoms. — They vary according to the location, char- 
acter, and duration of the tumor. Among symptoms common 
to all cerebral tumors is headache, which is constant, and at 
times very severe ; localized, but may be general. Nausea 
and vomiting frequently begin early, are constant symptoms, 
and often prevent retention of nourishment. Optic neuritis, 
single or double, complicates most cases. Vertigo, impaired 
hearing, convulsions, drowsiness, loss of memory, slow pulse, 
and constipation. 

Local conditions of anaesthesia, pricking, numbness, hemi- 
plegia, tonic or clonic muscular spasms, and ataxic symptoms. 

Diagnosis. — A positive diagnosis cannot be made directly, 
but by exclusion. 

Prognosis. — Unfavorable, except in syphilitic cases, where 
moderately favorable results may be expected. 

Treatment. — In syphilitics, treat with alteratives and ab- 
sorbents, as indicated in the tertiary stage of syphilis (see 
p. 101). Surgical operations promise much in a select line of 
cases. Treat symptomatically as indicated by each case. 



400 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 



INSOLATION. 

Varieties. — (1) Sun-stroke; (2) heat-stroke. 

Description. — (1) Sun-stroke is caused by prolonged ex- 
posure to the direct rays of the sun or high temperature. It 
begins suddenly with a dull feeling in the head; headache; 
dimness of vision ; nausea ; giddiness ; and loss of conscious- 
ness. Temperature is abnormally high, and varies from 106° 
to 112° F., or higher ; skin is dry and hot ; urine high-colored 
and scanty ; muscles relaxed but not paralyzed ; pupils do not 
respond to light ; stertorous respiration ; flushed face, and 
vessels prominent; heart is over-active and strong;. muscular 
tremors or convulsions ; occasional remissions of wild delirium. 
Death may ensue from hyperpyrexia, convulsions, or coma. 
Recovery is slow, and followed by unpleasant sequela?, such as 
headaches, vertigo, impairment of intellect, insomnia, general 
debility, and a general tendency to return on slightest ex- 
posure. 

(2) Heat-stroke is similar to sun-stroke, but never so severe 
or serious. It begins by dizziness, slight nausea, weakness, 
paleness of the skin, weak pulse, and rapid respiration. It 
may become so pronounced that consciousness is lost. Tem- 
perature rarely rises above 105° F. In a few hours or days 
patient is as well as ever. 

Pathology — That of acute cerebral congestion. Lungs, 
kidneys, liver, and spleen often enlarged. Serous effusions 
into the ventricles of the brain. Blood is thick, dark, and has 
altered corpuscles. 

Treatment. — Sim-stroke. — Never delay one moment, but 
strip patient at once and bathe him all over with cold water. 
Put ice to the head, and pour cold water over the body until 
hyperpyrexia is diminished. Antipyretic drugs are too slow 



DISEASES OF THE BRAIN AND MEMBRANES. 401 

to be of any service. When hyperpyrexia is reduced, put 
patient in warm blankets, still continuing cold applications to 
the head, and administer sufficient morphina to keep quiet 
and to relieve pain. Let food be light, such as milk, beef- 
extracts, soups, and boiled rice. Meet all symptoms as they 
arise. Tonics when necessary. During convalescence, which 
should be in bed, administer iodides and alteratives. Estab- 
lish free action of bowels with salines. 

Heat-stroke. — Cold to the head; cold sponge-baths, if tem- 
perature is above 102° F. Stimulate freely with diffusible 
stimulants (ammonia, alcohol, or camphor), followed by strych- 
nina in small doses. Meet symptoms ; prohibit early return 
to active mental or physical work. 



PSYCHOSES. 



INTRODUCTION. 

The psychoses are a class of diseases affecting the mind, and 
are considered under the general term insanity. 

Mind is that immaterial power behind matter which con- 
stitutes the true man and his actions ; which embodies the 
understanding, reasoning faculties, and perceptions, and mani- 
fests itself directly through the cells of the central nervous 
system, and indirectly through the various anatomical mechan- 
isms of the body. 

Insanity (in, not; sans, sound), lunacy, is a loss of power to 
control one's own free will, with a lack of responsibility for 
their actions — a pathological condition of the mental faculties 
dependent upon some perversion of the mind by external or 
psychological causes. The differentiation between sanity and 
insanity, between a crank and a lunatic, is so uncertain that 
it is impossible to define where the one begins or the other 
ends. 

An illusion is a modification of perception whereby an ob- 
ject or impression is presented by one of the senses in a false 
light. A man is mistaken for a demon. Thunder is mistaken 
for a voice from heaven. 

An hallucination is a false perception of one of the senses, 
founded upon imagination only, and not dependent on ex- 
ternal impressions. They hear noises and voices ; see ghosts, 
angels, and devils ; smell sweet and foul odors — all of which 
are not recognized by others. 

402 



PSYCHOSES. 403 

A delusion is a peculiar form of mental exaltation in which 
.he patient imagines himself immensely wealthy ; a descendant 
from royalty ; about to reform the world ; thinks his friends 
are his enemies, and that they are conspiring to kill or poison 
him — all of which tends to violence in the end. It is to be ob- 
served that illusions and hallucinations depend upon sensory 
action, while delusions are entirely mental or imaginary. 

GENERAL ETIOLOGY. 

Mind manifests itself physiologically through a perfect or- 
ganism, and, being immaterial, is never diseased. Let this 
organism undergo changes, and the manifestations of mind 
will vary, even though the same mind exists back of the mech- 
anism. This is aptly illustrated by a fine musician who plays 
excellently on a perfect pipe-organ. Each combination thrown 
on simply intensifies the melody, but a faulty one is accident- 
ally set and produces an ignominious failure. The instrument 
is a,t fault and not the musician. Mind acts physiologically 
through certain groups of central nerve-cells, but renders 
itself absurd or violent when attempting to use others. The 
gradation of intelligence is dependent upon the high or low 
development and arrangement of central nerve-cells in various 
individuals, whereas the same power of mind is behind each. 
The etiology of insanity is shrouded in mystery in many cases, 
but a combination of circumstances exists which favors its 
development. 

Predisposing Causes. — Heredity is the great predisposing 
cause, and is most frequently transmitted from the mother 
to her daughters. Children of extremely nervous parents 
often develop insanity. Educated and well- trained persons 
are least susceptible. The changes of puberty and old age 
may excite it. Extreme work, required of a weak mind to 



404 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

keep pace with the demands of the day, is often pernicious. 
Dark, gloomy, damp, and foggy days predispose to mental dis- 
orders, while bright, fresh, and invigorating sunshine always 
cheers. 

Exciting Causes. — Direct injury to the head ; acute or chronic 
diseases ; epilepsy ; influenza ; sexual disorders and masturba- 
tion 5 intemperance ; indigestion ; constipation ; womb-dis- 
eases ; child-birth ; prolonged irritation of the mind or temper 
by study, jealousy, hatred, love, reverses, or great successes. 

CLASSIFICATION. 

Maudsley classifies insanity into affective and ideational in- 
sanity. 

Affective, emotional, or pathetic insanity is manifested by ab- 
normal actions. 

Ideational or intellectual insanity is shown by the improper 
use of words, sentences, rhetorical absurdities, irrational con- 
versation and reasoning. 

Insanity may be affective, ideational, or both. Ideational 
'nsanity is usually preceded by the affective form, the latter 
being the last to disappear during convalescence. We judge 
a person's sanity from his conversation or acts. Affective in- 
sanity is much more dangerous than the ideational, for in the 
former the first indication shown may be a violent act, while 
in the latter there is incoherent, absurd, or threatening talk, 
which soon leads to direct treatment or control. The diagno- 
sis of affective or em.otional insanity is often difficult. Pro- 
fessor J. K. Bauduy says: "Emotional insanity is therefore 
known to exist by the history of the case, the existence of 
hereditary predisposition, the presence of some well-known 
conditions of causation, the change of character, the cessation 
of social harmony with surroundings, the corroborative cir- 



PSYCHOSES. 405 

cumstances, the impaired judgment of relations, the measur- 
ing of the perversion according to an individual standard or 
to one accepted by the common sense or the general consent 
of mankind, the motiveless assaults upon relatives and inti- 
mate friends, the existence, of some of the physical symptoms 
of insanity ; in other words, our diagnosis is to be based upon 
all the above-mentioned states, the etiological conditions, the 
sequence of symptoms, and the general course of the affection." 

Affective insanity manifests itself in a moral form, in which 
the whole character of the patient changes from religious to 
profane moods ; from miserly to liberal actions. It also as 
sumes an impulsive form, where there is a constant menacing or 
irresistible desire to commit atrocious crimes or acts, independ- 
ent of any mental perversion and beyond control of the will. 

The legal responsibility of an insane person rests entirely 
upon the proof of the presence or absence of will-power. To 
inflict corporal punishment or the death penalty for a truly 
insane act is not legal, but such patients must be confined 
strictly in an asylum for life, if the offense be capital. 

MANIA. 

Definition. — Mania is a psycho-neurosis, recognized by a 
varying degree of mental excitement, irrational conversation, 
a pathological association of ideas, unnatural, excitable, wild 
movements and actions. It is divided into (1) acute delirious 
mania ; (2) acute mania ; (3) chronic mania. 

(1) ACUTE DELIRIOUS MANIA. 

Synonyms. — Delirium grave ; typhomania. 

Etiology. — Most common in women from twenty to thirty 
years of age. Often follows great mental shock from a death, 
disappointment in love, financial failures, parturition, insola- 



406 A SYNOPSIS OF THE PRACTICE OP MEDICINE. 

tion, or alcoholic excesses. It may develop in cases of tuber- 
culosis or any of the acute diseases. It sometimes occurs 
periodically. Epileptics are liable to develop it. 

Symptoms. — Onset is usually very sudden and violent, 
when patient may sing, cry, laugh, scream from fear, or attack 
those around her. Her delusions are not constant, and are 
thus characteristic. Insomnia is an early symptom ; sexual 
desire is increased, and the appetite voracious. Temperature 
varies from one to six degrees above normal, and the condi- 
tion may lapse into a typhoid condition called typhomania. 
Rapid pulse ; tongue dry and coated ; profuse fetid perspira- 
tion; great asthenia and prostration. Vaso-motor changes 
are common. It rapidly progresses to a fatal termination by 
coma, collapse, or exhaustion in a few days or weeks, or gradu- 
ally subsides, leaving impairment of some of the mental facul- 
ties or chronic mania. 

Pathology. — Brain and membranes are greatly congested 
and ©edematous. The ganglia are opaque and granular, and 
the spaces filled with blood-elements. The vessels of the pia 
mater are often surrounded by leucocytes. 

Diagnosis. — Acute meningitis is preceded by headache, 
drowsiness, tingling and numbness of the extremities, and 
followed by rapid pulse, high temperature, and optical illu- 
sions ; pupils often contracted, and stomach irritable. 

Delirium tremens manifests itself by anxious expression, 
alarm, good-nature, restlessness, moist skin, soft pulse, moist 
tongue, and history. A few days will serve to differentiate. 

Prognosis. — Typhoid symptoms, depression of feeling, and 
rapid pulse are unfavorable. Death may be very sudden. 
Mortality is high. Cheerful and gay delirium and sleep are 
favorable signs. 

Treatment. — Removal to an asylum is not absolute^ neces- 
sary, nor is it desirable if proper attention can be given at 
home. The patient should be placed in a dark room where 



PSYCHOSES. 407 

everything has been removed which might be used in self -in- 
jury, and should be under the constant care of a good, strong, 
attentive, commanding nurse. Relatives and visitors must be 
excluded except in special cases. The patient's condition must 
not be discussed nor mentioned in his hearing. The most 
nutritious, albuminous food must be given at regular inter- 
vals of three or four hours. They require considerable water, 
and it must not be withheld. Stimulants should not be given 
as a routine practice, but only when indicated. 

Insomnia must be met with chloral, one-half to one dram 
at a dose. Sulphonal, gr. x-xx, in hot tea is also recommended, 
but should never be continued, as it is too depressing, and 
the habit of using it may be acquired. Sleep is usually fol- 
lowed by an absence of delirium, but the delusions still re- 
main. Opium is followed by aggravation of symptoms. 
Delirium and high temperature are best reduced by a cold 
bath under the usual precautions. Warm baths are some- 
times followed by sleep. Meet all untoward symptoms and 
complications as they arise. 

(2) ACUTE MANIA. 

Synonyms. — Raving madness ; raving insanity. 

Etiology. — May follow simple mania or melancholia. It 
is not a disease of young adults, but often present after the 
fortieth year in nervous temperaments. Hereditary. 

Symptoms.— Premonitory, when present, are delusions of a 
mild type ; change of character, disposition, and habits ; head- 
ache, restlessness, and mind not perfectly clear ; a f eeling of 
impending calamity ; a great desire to do something wrong or 
violent ; insomnia or disturbed sleep j and a peculiar piercing 
luster to the eye. It may begin suddenly, without premoni- 
tory signs, with great mental excitement, violent raving, shout- 
ing, singing, laughing or crying, which continues for hours 
or days without intermission. Personal injury, self-abuse, 



408 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

entire change of manner, or violence to surroundings. Con- 
versation is rambling and disconnected. Delusions are not 
fixed. Actions are more or less spasmodic and violent. Great 
self -exaltation and esteem. Insomnia ; constipation. Tem- 
perature is rarely above 99° to 100° F. Delirium is entirely 
absent. Thought is almost immediately followed by action. 
The disease may rapidly progress to dementia, chronic insan- 
ity, or melancholia. 

Pathology. — General irritation of the brain from hyperae- 
mia. Cerebral anaemia may be present in some cases. The 
pathological conditions of the various brain-centers cannot be 
accurately demonstrated, but they are undoubtedly involved, 
thus producing the great stimulation of thought and action, 
accompanied by a lack of inhibition. 

Prognosis. — The presence of fixed delusions or previous 
debilitating disease is bad. Recovery may be very sudden, in 
a few days, weeks, or months. It may progress to dementia 
or chronic insanity. Relapses are very common. 

Treatment. — Send to an asylum at once where moral treat- 
ment is strictly enforced and a system of rewards and punish- 
ments adhered to according to merit. When there is cerebral 
congestion, the bromides should be administered in full doses ; 
in anaemic conditions they should be avoided. Applica- 
tions of cold to the head and spine as indicated. Insomnia 
must be combated with chloral, gr. x-xl, sulphonal, gr. x-xx, 
or hyoscyaminae sulph., gr. T io> hypodermically. Conium is 
suggested when there is great motor excitement. The most 
nutritious food must be administered regularly, even though 
the stomach-tube is necessary. 

(3) CHRONIC MANIA. 

Description. — The exact stage at which acute mania be- 
comes chronic is not definitely determined, but writers claim 



PSYCHOSES. 409 

that when it is from three to twelve months' duration it may 
be called chronic. It manifests itself ver} r mnch like the acute 
form, with these differences : the raving is not so constant, but 
intermits, with periods of comparative or complete quiescence. 
The delusions assume a less rambling form and tend to be- 
come fixed. There may be a period of complete rationality, 
or the loss of will and volition is fixed. 

Monomania is a form of chronic insanity characterized by 
delusions upon one or more constant points, with aD appar- 
ently rational mind upon all other subjects. Such is not the 
case, for a partial insanity is an impossibility, even though 
the patient may seem sound on other points. There is an 
unusual degree of self-esteem and personal exaltation which 
greatly excites the patient if he is antagonized in this respect. 
He imagines himself wealthy, very strong, a saint, an apostle, 
or he may think that certain persons are conspiring against 
his life by poisoning his food or lying in wait for him. Illu- 
sions sometimes exist. Hallucinations may develop, when 
they see a certain spirit, hear imaginary voices, or converse 
with departed spirits. Monomania is usually the result of 
acute insanity. 

Pctrancea is a primary monomania, produced without definite 
cause, in which the power and strength of the mind are not 
lost at. first, but which tends to assume the distinct form of 
monomania. It is usually hereditary. Such patients are 
termed cranks. Parancea receives the name of protopatMc 
insanity, insane diathesis, or unsoundness of mind. 

Chronic insanity may exist for years without affecting the 
duration of life. Recovery is usually hopeless. Monomaniacs 
in their earliest stages may be cured, but if the delusions are 
fixed for six or eight months it is doubtful. Paranoea may 
recover, but tends to fixed delusions and dementia. 

Treatment. — Asylum treatment is indicated, and a strict 



410 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

moral influence exerted. Violence must be avoided. Control 
insomnia and complications as indicated. 

ACUTE DEMENTIA. 

Description. — Acute dementia is a sudden or gradual loss 
of reason or mind, occurring almost exclusively in persons 
under forty years of age. Among prominent causes are great 
mental excitement, shocks from fright, grief, or accident; 
mental exhaustion from prolonged work ; exposure to intense 
cold or heat ; sexual excesses ; recovery from asphyxiation ; 
neurotic predisposition ; syphilis ; and acute diseases — typhoid 
fever. 

Patient suddenly or gradually assumes a blank, idiotic, or 
ignorant expression. Voice is low and muttering, and every 
bodily movement is slow and indolent. Pulse is very weak ; 
respiration shallow and slow ; movements automatic ; ana?s- 
thesia of the skin ; mouth is open and saliva dribbles j skin is 
cold ; pupils sluggish or inactive 5 and personal uncleanliness. 
The characteristic symptom is the complete loss of knowledge. 
Professional men know no more than a baby, and cannot do 
the simplest sums nor answer intelligently. Little attention 
is given to personal address, and the ideas cannot be collected. 
Cataleptic states may develop. 

Recovery is rare in extreme cases, or when complicating 
phthisis or pneumonia. The general tendency is to gradual 
recovery, complete or partial, with the affected period of life 
a perfect blank. 

Treatment. — These patients are best treated at home if 
proper care can be given. They require as much attention as 
a young child. Albuminous food must be administered at 
intervals of four to six hours, even though the stomach-tube 
is necessary. Quinine, strychnine, iron, arsenic, and manga- 



PSYCHOSES. 411 

nese are of service as indicated. Systematic exercise and 
massage. Galvanism of the head has been nsed to advantage. 
Apply warmth as necessary, and always wear wool or flannel 
next the skin. 

CHRONIC DEMENTIA. 

Description. — Chronic, terminal, or secondary dementia is 
a loss of mental power as a result of acnte insanity or melan- 
cholia — the ultimate result to which all forms of mental affec- 
tions tend. Chronic imbecility. Very old people may lapse 
into a similar condition from age alone. The general appear- 
ance is characteristic. There is a vacant stare and blank ex- 
pression on the face ; looks much older than he really is ; gait 
is uncertain, and bodily strength rather feeble. He may have 
a mania for walking, running, standing still, crouching in a 
corner, dancing, or hopping. The finer emotions are not capa- 
ble of impression. Disposition is usually happy, but may be 
gloomy, morose, depressed, mischievous, or revengeful. Delu- 
sions, hallucinations, and illusions are fixed. They will nurse 
a bottle, stick, or any object for a baby, and engage in all 
such similar practices. Personal habits are often filthy, and 
morals depraved. 

The impairment of mind varies. It may be a perfect blank 
concerning the past and present events ; the past may be clear 
and the present impaired. The nearest friends and relatives 
may not be known, and after conversing with any one the 
fact is forgotten at once. He may live over past years and 
imagine himself young again. 

General health is good, but they are subject to phthisis and 
intercurrent diseases. Constant care is necessary to prevent 
personal neglect. The prognosis is very unfavorable, and re- 
covery is the exception. Confinement in an asylum is not 



412 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

necessary, unless there be a tendency to violence or revenge. 
Make them exercise daily ; give frequent baths ; do not allow 
them to lie long in bed, as obstinate bed-sores will form. 



MELANCHOLIA. 

Description. — Melancholia is a form of affective insanity, 
manifested by extreme depression of spirits, despondency, 
great feeling of dejection and sorrow, which is beyond control 
of the will, and often referred to some imaginary cause. Some 
patients will sit or stand for hours in the same position, ap- 
parently oblivious of their surroundings, with an agonized 
expression on their face. Others are very restless and pass a 
great part of the time in crying, moaning, walking to and fro 
in their room, wringing their hands, and constantly censuring 
themselves for some imaginary wrong or sin. At first there 
may be lucid intervals, but the patient is liable to lapse into 
permanent delusions. They have committed the unpardon- 
able sin or murder, or have some bad disease, pains, parasites, 
and animals in the intestinal tract. Insomnia and an anaes- 
thetic condition of the skin. Most common after the fortieth 
year, but may occur at any age. Melancholia accompanied by 
delusions is termed lypemania. When there is extreme fear 
and terror without referable cause, it is termed pantophobia. 
The general condition of melancholia seems to depend upon 
anaemia of the brain. 

Hypochondriacal melancholia is manifested by a constant 
study, investigation, and brooding over supposed bodily de- 
fects or diseases, which in time leads to more or less disease, 
fixed delusions, and uncontrollable actions. Maudsley relates 
a case where a patient penetrated his intestines with a piece 
of glass, " to let out the gas." These patients constantly talk, 



PSYCHOSES. 413 

study, and consult about their supposed ailments. If you can 
divert their mind for a time, all imaginary disease disappears 
temporarily. 

Furor mdancJiolicus, or melancholy with excitement, is 
sometimes mistaken for mania. There are delusions, great 
depression, deep mental anxiety, and tendency to suicide or 
homicide. Such patients, when asked their reason for homi- 
cide, will say that it was not for spite, but on account of 
an irresistible desire to kill a certain person. They conceal 
knives, pins, needles, or glass for accomplishing their mur- 
derous desires. The paroxysms are often periodical, and the 
patient requires a constant watch. 

Melancholia attonita, or melancholia with stupor, is char- 
acterized by what might be termed "vegetable life." They 
refuse all food for fear it is poisoned; will remain for hoars 
or days in the same position, with little or no movement ; the 
face is without expression ; they are unconscious to surround- 
ings. One delusion or idea is liable to concentrate the mind 
for days. Periods of comparative repose and rational exist- 
ence may occur. It is analogous to catalepsy. 

Circular insanity (folie circulaire) is a condition of alteration 
between the manifestations of mania and melancholia. The 
patient may be melancholic for a season, become maniacal for 
a short time, and thus alternate indefinitely. This form is 
very grave and often terminates in dementia. 

Treatment. — Asylum treatment, based upon moral prin- 
ciples, is best, for a more speedy recovery is possible. They 
may be kept under the strictest eye and placed in such posi- 
tions that they can do themselves or others no physical harm. 
When depressed they should be encouraged 5 when excited, 
calm and soothe them, even though physical force is necessary. 
Deal with them as you would with children, and give proper 
rewards and punishments. Milk, beef -juice, and nitrogenous 



414 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

foods must be given regularly, by the stomach-tube if neces- 
sary. Attend to constipated conditions at once, and keep the 
bowels regular with cascara, aloin, strychnina, and belladonna. 
Headache is relieved by acetanilide or phenacetin combined 
with strychnine or caffeine. Insomnia must be controlled 
with chloral, sulphonal, or paraldehyde. Alcoholics are some- 
times beneficial. 

MORAL INSANITY. 

Description. — Baucluy says: "It is never moral depravity, 
and moral depravity is not always moral insanity."' If a 
steady, conscientious, religious, moral man were to suddenly 
change into a life of lust, lasciviousness, murder, association 
with bad company, profanity, and open self -pollution without 
cause, and such a man had come from a highly neurotic or 
insane family, he would be called morally insane. A close in- 
vestigation into the previous history will usually show certain 
inexplicable peculiarities or change of character. Fagge says : 
" When once we have given up the arbitrary notion that the 
presence or absence of delusions determines whether the in- 
tellectual faculties are or are not impaired, there seems to me 
to be no basis whatever for the doctrine that ' moral insanity ' 
is to be regarded as a separate form of mental disorder." 



IDIOCY. 

Definition. — Idiocy is a congenital form of insanity due to 
an arrest of cerebral development during gestation or soon 
after birth, and is to be distinguished from imbecility, which 
may occur at any time after birth as a result of some patho- 
logical condition, injury, or disease. 



PSYCHOSES. 415 

Symptoms. — They vary in degree with each case. The 
worst cases are absolutely helpless; cannot talk or utter a 
sound ; take no interest in surroundings ; are oblivious of 
time ; and will never manifest a desire for food. Some can 
utter slight sounds or monosyllables, and move the face or 
extremities. When we pass to a higher form where there is 
recognition, action, and motion, the case is probably one of 
imbecility. That these patients are really impressed with 
points about which they seem to be oblivious is shown by the 
supervention of acute diseases which may cause them to speak 
about these very subjects. The senses, with the exception of 
sight, are greatly blunted or dormant. Sexual function and 
development are poor, and often entirely suppressed. There 
is liability to dwarfing and imperfect body development. 

Pathology. — Inflammation, and the excessive use of lime 
salts in young children, may be classed as causes. It develops 
mostly in children of the nervous or insane temperament. 
The head is microcephalic, imperfectly developed, and the 
sutures close early. The brain is small and may weigh from 
fourteen to twenty ounces. Its surface presents comparatively 
few convolutions and shallow sulci. The hemispheres are 
poorly developed, and one may be larger than the other. The 
ventricles are sometimes filled with fluid, and the brain sub- 
stance is very thin. Sclerosis of the brain is present in some 
cases. 

Prognosis. — Very grave. Most cases are hopelessly idiotic. 
A change may be produced by great care and nursing. 

Treatment. — When proper care cannot be given at home, 
they should be placed in an asylum. Linear craniectomy has 
been done by home operators, with a view of increasing the 
intracranial cavity and giving the brain room to expand and 
develop. These cases -have been reported as improved, but 
time must elapse before the method can be proved and adopted. 



416 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 



CRETINISM. 

Description. — Endemic cretinism is a peculiar form of idiocy, 
characterized by marked deformity of the cranium, face, and 
body. The mind is the same as found in idiocy. Cretins are 
rarely more than four or five, and may be only three feet tall. 
Fagge says : " They have large heads, especially in the direc- 
tion from ear to ear. The features are broad and thick ; the 
eyes are wide apart; the nose is very flat at the root, and 
spreads out enormously toward the alee ; the mouth is very 
large, widely open, with thick lips, and allows the saliva to 
escape. The forehead, and cheeks are wrinkled, and the skin 
is coarse and rough, so that they have always the appearance 
of old age. A cretin thirty years old is exactly like a cretin 
of forty. The hair comes low on the forehead and is coarse 
and bristly. Cretins have narrow chests, large bellies, crooked 
limbs. Their hands are broad but short, with short fingers." 
Goiter is almost always present in districts where cretinism 
is present, and may exist in many cases. Some of the typi- 
cal cases show no goiter. Virchow believes that the result- 
ing deformity in the head is due to an early osseous union 
of the occipital and sphenoid bones at the base of the 
skull, thus preventing enlargement of the base antero-pos- 
teriorly. 

Sporadic cretinism? occurs in any part of a country, and is 
also closely related to goiter. In most cases the thyroid gland 
is very small or absent, but in its place are found two swell- 
ings or soft lumps outside the sterno-mastoid muscle and above 
the clavicle, which are made up of fatty tissue and are pink in 
hue. They vary from the size of a hazel-nut to a good-sized 
duck-egg. The same mental condition exists as in the other 
forms, but they are usually quiet and easily controlled. 



PSYCHOSES. 417 

Cretinoid Condition. — Sir William Gull cited a case similar 
to cretinism occurring in an adult woman. The eyes became 
wide apart ; nose flat, broad, sunken, and thick ; lips thick ; adi- 
pose tissue under the chin and eyes increased ; large tongue ; 
unwieldy hands ; and marked change of disposition. 

Treatment. — Entirely symptomatic, and cures have not 
been reported. 

DEMENTIA PARALYTICA. 

Synonyms. — General paralysis of the insane ; progressive 
paralysis of the insane ; and, improperly, " general paralysis." 

Definition. — A disease of middle life, characterized by a 
great mental change, dementia, general tremor, unequal, slug- 
gish, pin-point pupils, and progressive paralysis, which tends 
to fatality. 

Etiology. — Most common in blonde men between the ages 
of thirty-five and fifty years. More common in towns and 
cities. General insanity. Sexual excesses ; great nervous 
shock from business failures • or injury to the head. Syphilis 
is said to cause a large number of cases. May be hereditary. 

Symptoms. — The earliest symptoms noticed are referable 
to character. He is absent-minded ; forgets readily ; becomes 
careless in habits and dress 5 spends his money with great 
freedom; has spells of dullness and moodiness; forgets his 
meals and appointments; has insomnia and poor appetite. 
The pupils may be unequal or greatly contracted, and do not 
respond to light readily. In a few days or weeks chronic 
delusions develop, and he imagines himself a king, banker, 
reformer, a millionaire, or he may think that his friends are 
conspiring against his life. 

Accompanying this condition is a peculiarity of articulation. 
He mixes long words ; does not enunciate distinctly ; hesitates, 



418 A SYNOPSIS OF THE PRACTICE OF MEDICINE. 

stops, or substitutes the wrong word in a sentence. The 
tongue and lips tremble when he is told to hold them still. 
There is a slight tremor of the hand. The gait is unsteady 
and stiff, and he falls readily. Sometimes the walk is like 
an ataxic. High reflexes ; the pupils remain unequal or con- 
tracted. Transitory paralysis is common and lasts for a few 
hours or days. Attacks of raving and violent insanity. 

Improvement may follow and the patient seem cured, but 
relapse is the rule. Some progress rapidly to complete paral- 
ysis and dementia, with a fatal termination in one to five years 
from the onset. Death is the result of personal violence, bron- 
chitis, or pneumonia. Complete recovery never occurs. 

Pathology. — There does not seem to be any definite patho- 
logical process demonstrable. Autopsy has shown a thicken- 
ing of the pia mater, with adhesions to the convolutions of 
the brain in some cases, and in others the pia mater is sepa- 
rated from the brain by fluid. The arachnoid is often thick- 
ened ; pachymeningitis and hematoma of the dura mater have 
been demonstrated. Weight of brain is diminished. Authors 
differ as to whether the condition is one of " a diffused inter- 
stitial cortical encephalitis " or " a diffused parenchymatous 
cortical encephalitis." The spinal cord presents changes not 
unlike the different forms of sclerosis. The nerves undergo 
changes, and the axis-cylinders are exposed, atrophied, or ob- 
literated. General atheroma. 

Diagnosis. — Impaired speech, motionless, contracted pu- 
pils, increased reflexes, mental impairment, tremors, and paral- 
ysis will serve to diagnose it in the early stages. 

Prognosis. — Temporary improvement is frequent, but a 
permanent cure is impossible. Every true case is necessarily 
fatal in three to five years. 

Treatment. — Very unsatisfactory, and must be symptom- 
atic. Chloral and bromides for insomnia and convulsions. 



PSYCHOSES. 419 

Keep bowels active. Confine in an asylum if violent dementia 
appears. Tonics as indicated. Shaw and Tuke each opened 
the cranium to diminish intracranial tension and thus bring 
about a reaction, but with temporary success. In syphilitic 
cases use iodides and mercury in full doses. 



INDEX. 



Abdomen, tumors of, 230. 
Abdominal reflex, 345. 
Abscess, cerebral, 398. 
hepatic, 248. 
metastatic, 156. 
of floor of mouth, 187. 
of stomach, 198. 
perinephritic, 277. 
retro-pharyngeal, 186. 
Acetanilide, pill, comp., 27. 
Acid, hydrochloric, test for, 204. 
lactic, in rheumatism, 111. 

test for, 204. 
nitric, for albumin, 264. 
picric, 264. 

salicylic, in rheumatism, 112. 
uric, in gout, 105. 
test for, 265. 
Acme, 18. 

Aconite in fever, 24. 
Adhesions, pericardial, 140. 

pleural, 336. 
iEgophony, 294. 
Agraphia, 394. 
Ague, 47. 

cake, 51. 

double quotidian, 48. 

tertian, 48. 
dumb, 48. 
quartan, 48. 
quotidian, 48. 
i tertian, 48. 
Albumin, tests for, 263. 
Albuminuria, scarlatinal, 62. 
Alcoholism, 395. 
Allopathic treatment, 10. 
Amygdalitis, 181. 
Anaemia, 146. 

essential, 150. 
idiopathic, 151. 
malignant, 151. 
primary, 150. 



Anaemia, prog, pernicious, 151. 

secondary, 146. 

symptomatic, 146. 
Anaesthesia, 343. 
Analgesia, 343. 
Anatomy, topographical, 289. 
Anchylostomum duodenale, 235. 
Aneurysm, 142. 

thoracic, 143. 
Angina Ludovici, 187. 

membranous, 77. 
pectoris, 136. 
Anode, 343. 
Anthrax, 89. 

Antipyretic measures, 22. 
Antiseptics, intestinal, 221. 
Aortic diseases, 131. 

insufficiency, 131. 
murmurs, 121. 
stenosis, 132. 
Apex-beat, 119. 
Aphasia, 394. 
Aphemia, 394. 
Aphthae, 166. 

confluent, 166. 

discrete, 166. 
Apneumatosis, 322. 

acquired, 323. 
congenital, 323. 
Apoplexy, cerebral, 393. 
Appendicitis, 215. 
Arcus senilis, 126. 
Argyll-Robertson pupil, 381. 
Arthritis, gonorrhoea^ 113. 

rheumatic, 109. 
Ascaris lumbracoides, 236. 
Ascites, 241. 
Asphyxia, 307. 
Asthma, bronchial, 325. 

cardiac, 326. 

hay, 298. 

spasmodic, 325. 



421 



422 



INDEX. 



Ataxia, hereditary, 383. 
locomotor, 380. 
Ataxy, locomotor, 380. 
Atelectasis, 322. 

Atrophy, acute yellow, of liver, 255. 
Aura, epileptic, 348. 
Auscultation, 292. 
Axis, cerebro-spinal, 342. 

Bacillus anthracis, 89. 
comma, 75. 
lacticus, 194. 
malarias, 51. 
tetanus, 87. 
tuberculosis, 91. 
typhosus, 40. 
Baths, cold, 23. 
Beriberi, 101. 
Bile-ducts, catarrh of, 257. 
Bilharzia heematobia, 282. 
Bilious attack, 195. 
Biliousness, 247. 
Bladder, anaesthesia of, 286. 
catarrh of, 283. 
diseases of, 283. 
hyperesthesia of, 285. 
hypertrophy of, 284. 
paralysis of, 287. 
Blood, diseases of, 145. 
poisoning, 154. 
vomiting of, 208. 
Blood-vessels, diseases of, 142. 
Bones, rickety, 108. 
Bothriocephalus latus, 235. 
Brain, abscess of, 398. 

compression of, 392. 
concussion of, 391. 
congestion of, 390. 
diseases of, 385. 
inflammation of, 392. 
softening of, 392, 393. 
tumors of, 398. 
Break-bone fever, 68. 
Bright's disease, acute, 268. 

amyloid, 273. 
chronic, 269. 
cirrhotic, 271. 
Bromides, the, 351. 
Bromoform, 83. 

Bronchial tubes, diseases of, 311. 
Bronchiectasis, 315. 
Bronchitis, 31 1 . 

acute, 311. 



Bronchitis, capillary, 316. 

chronic, 314. 

croupous, 313. 

diphtheroid, 313. 

membranous, 313. 

plastic, 313. 

sicca, 314. 
Bronchophony, 294. 
Broncho-pneumonia, 316. 
Bronchorrhcea, 315. 
Bruit, 143. 

de diable, 147. 
Buboes, 36. 

Cachexia, malarial, 51. 

tubercular, 94. 
Caecum, inflammation of, 215. 
Calculi, biliary, 258. 
hepatic, 258. 
oxalic, 279. 
phosphatic, 279. 
renal, 279. 
uric acid, 279. 
Camp fever, 32. 
Cancer, hepatic, 253. 
in mouth, 174. 
pancreas, 244. 
stomach, 203. 
intestinal, 229. 
renal, 278. 
Cancrum oris, 167. 
Carbuncle, 89. 
Cardiac dilatation, 124. 

hypertrophy, 122. 
murmurs, 121. 
Cardialgia, 209. 
Carnification, 323. 
Catabolism, 148. 
Catalepsy, 352. 

Catarrh, bronchial, acute, 311. 
chronic, 314. 
dry, 314. 
duodenal, 214. 
epidemic, 24. 
fetid, 315. 
gastric, acute, 193. 

chronic, 196. 
drunkard's, 196. 
intestinal, 213. 
nasal, acute, 295. 

chronic, 296. 
of bile-duct*. 257. 
caecum, 215. 



INDEX. 



Catarrh, of rectum, 217. 
pharyngeal, 177. 
suffocative, 316. 
summer, 299. 
Cephalalgia, 104. 
Cephalodynia, 104. 
Cerebritis, 392. 
Cerebro-spinal axis, 342. 
fever, 30. 
meningitis, 30. 
typhus, 30. 
Ceylon disease, 101. 
Chancre, hard, 99. 

Hunterian, 99. 
Changes, trophic, 344. 
Charbon, 89. 
Chest, cold on the, 311. 
Cheyne-Stokes breathing, 293. 
Chicken-pox, 54. 
Child-crowing, 305. 
Chills and fever, 47. 
Chlorides, tests for, in urine, 265. 
Chlorosis, 150. 
Cholera, 73. 

Asiatic, 73. 
bilious, 219. 
English, 219. 
epidemic, 73. 
infantile, 222. 
infantum, 222. 
morbus, 219. 
nostras, 219. 
sporadic, 73. 
Cholerine, 75. 
Chorea, 346. 

hysterical, 346. 
Chyluria, 282. 

Circulatory system, diseases of, 119. 
Cirrhosis of kidney, 271. 
liver, 250. 
lung, 333. 
stomach, 207. 
Clonus, 345. 

ankle, 345. 
Cold, local application of, 22. 
Colic, hepatic, 258. 

intestinal, 232. 
lead, 232. 
renal, 279. 
stomachic, 209. 
Colitis, 226. 

ulcerative, 226. 
Coma, diabetic, 115. 



Coma, urasmic, 266, 395. 
Comma bacillus, 75. 
Complications, 9. 
Confluent varicella, 54. 

variola, 56. 
Congo paper, 204. 
Constipation, 233. 
Consumption, 94. 

galloping, 92. 
non-tubercular, 332. 
pulmonary, 332. 
tubercular, 94. 
Contagious fevers, spread of, 20. 
Contents, 13. 
Convalescence, 18. 
Convulsions, infantile, 225. 

uraemic, 266. 
Corpuscles, red blood, 145. 

white blood, 146. 
Coryza, acute, 295. 

chronic, 296. 
Costiveness, 234. 
Cough, stomach, 197. 

winter, 314. 
Cowpox, 58. 
Cramp colic, 232. 

writers', 363. 
Cranks, 409. 
Cremasteric reflex, 345. 
Cretinism, endemic, 416. 
sporadic, 416. 
Cretinoid condition, 417. 
Crises, gastric, 381. 
Crisis, 9, 18. 
Croup, catarrhal, 305. 
false, 305. 
membranous, 307. 
pharyngeal, 181. 
spasmodic, 304. 
true, 307. 
Cutaneous reflexes, 345. 
Cutis anserina, 47. 
Cynanche, 181. 
Cystitis, acute, 283. 

chronic, 283. 
Cysts, hydatid, of kidney, 282. 
liver, 254. 
ovarian, 242. 

Dance, St. Vitus's, 346. 
Dandy fever, 68. 
Defervescence, 18. 
Definition, 8. 



424 



INDEX. 



Degeneration, reaction of, 344. 
Delirium, grave, 405. 

tremens, 406. 
Delusion, 403. 
Dementia, acute, 410. 
chronic, 411. 
paralytica, 417. 
secondary, 411. 
terminal, 411. 
Dengue, 68. 
Desquamation of measles, 65. 

scarlatina, 61. 
Diabetes, 114. 

insipidus, 113. 
mellitus, 114. 
Diagnosis, 9. 

differential, 289. 
physical, 289. 
Diarrhoea, 213. 

choleraic, 74. 
elimination in, 221. 
inflammatory, 224. 
summer, 224. 
Diastole, 120. 
Diathesis, 8. 

hemorrhagic, 160. 
insane, 409. 
tubercular, 91. 
Diet in fever, 22. 
Digitalis in scarlatina, 63. 
Dilatation, cardiac, 124. 

of oesophagus, 191. 
stomach, 206. 
Diphtheria, 77. 

bronchial, 313. 
laryngeal, 307. 
nasal, 78. 
of the mouth, 167. 
paralysis of, 79. 
Diplococci, 30. 
Disease, 7. 

Addison's, 162. 
bad, 98. 
Basedow's, 137. 
bleeders', 160. 
Ceylon, 101. 
Charcot's, 382. 
contagious, 7. 
Corrigan's, 333. 
Duchenne's, 379. 
endemic, 8. 
epidemic, 8. 
Friedreich's, 383. 



Disease, functional, 7. 
Graves's, 137. 
Hodgkin's, 152. 
infectious, 7. 
organic, 7. 
Parkinson's, 360. 
prophylaxis of contagious, 

21. 
sporadic, 8. 
Thomsen's, 354. 
valvular, 130. 
Disinfection, 21. 
Dropsy, abdominal, 241. 
asthmatic, 101. 
of pelvis of kidney, 275. 
pericardial, 141. 
peritoneal, 241. 
pleural, 341. 
Duodenitis, 214. 
Duodenum, catarrh of, 214. 
Dysentery, acute, 226. 

catarrhal, 227. 
chronic, 228. 
diphtheritic, 227. 
epidemic, 226. 
gangrenous, 227. 
mild, 217. 
Dyspepsia, 210. 

atonic, 210. 
nervous, 210. 
Dysphagia, 189. 

Echinococcus hominis, 282. 
Eclampsia, 266. 
Effusion, pericardial, 141. 

pleural, 342. 
Electrical reactions, 343. 
Electricity, faradic, 344. 
galvanic, 343. 
static, 344. 
Elimination, 10. 
Embolism, cerebral, 396. 
Embolus, 396. 
Emphysema, compensatory, 324. 

vesicular, 324. 
Empyema, 339. 
Endocarditis, acute, 128. 

chronic, 130. 

diphtheritic, 128. 

septic, 129. 

ulcerative. 128. 
Enteralgia. 232. 
Enteric fever, 37. 



INDEX. 



425 



Enteritis, 213. 

catarrhal, 224. 
Enteroclysis, 76. 
Enuresis, 286. 
Ephemeral fever, 23. 
Epidemic catarrh, 24. 

cerebrospinal meningitis, 
30. 

cholera, 73. 
Epilepsy, 348. 

abortive, 348. 

cardiac, 137. 

hysterical, 350. 

Jacksonian, 349. 

major, 348. 

minor, 349. 

partial, 348. 
Erysipelas, 69. 

phlegmonous, 70. 
puerperal, 71. 
Etiology, 8. 

Exophthalmic goiter, 137. 
Exophthalmos, 137. 

Fainting, 211. 
Famine fever, 28. 
Faradic electricity, 344. 
Fastigium, 18. 

Fatty degeneration of heart, 126. 
liver, 253. 
Febricula, 23. 
Febris recurrens, 28. 
Fehling's solution, 264. 
Fermentation test for sugar, 116. 
Fever, 17. 

bilious, 193. 

malignant, 44. 
relapsing, 28. 
remittent, 48. 

break-bone, 68. 

camp, 32. 

cerebro-spinal, 30. 

chills and, 47. 

congestive, 49. 

contagious, 19. 

dandy, 68. 

diet in, 22. 

endemic, 19. 

enteric, 37. 

entero-mesenteric, 37. 

ephemeral, 23. 

epidemic, 19. 

eruptive, 19, 54. 



Fever, famine, 28. 
gastric, 193. 
hay, 298. 
idiopathic, 19. 
infectious, 19. 
intermittent, 19, 47. 
irritative, 23. 
jail, 32. 
lung, 328. 
malarial, 46. 
malignant bilious, 44. 

intermittent, 49. 
malarial, 49. 
marsh, 48. 
Mediterranean, 44. 
mild malarial, 47. 
neurotic, 19. 
paludal, 47. 
pernicious, 49. 

malarial, 49. 
putrid, 32. 
relapsing, 28. 
remittent, 19, 48. 
rheumatic, 109. 
rose, 299. 
sailor's, 44. 
scarlet, 60. 
ship, 32. 
simple continued, 18, 23. 

essential, 23. 
specific, 19. 
splenic, 89. 
sporadic. 19. 
spotted, 30. 

spread of contagious, 20. 
stupid, 32. 
symptomatic, 19. 
typhoid, 37. 
typhomalarial, 49. 
typhus, 32. 
yellow, 44. 
Fevers, congestive, 49. 
continued, 23. 
eruptive, 54. 
malarial, 46. 
periodical, 44. 
spread of contagious, 20. 
Filaria sanguinis hominis, 281. 
Fistula, rectal, 219. 
Flux, bloody, 226. 
Fluxion, splenic, 261. 
Folie circulaire, 413. 
Fracture, green-stick, 108. 



426 



INDEX. 



Fremitus, 291. 

Functions, localization of, 342. 

Furor melancholicus, 413. 

Gall-stones, 258. 
Galvanic electricity, 343. 
Gastralgia, 209. 
Gastritis, 193. 

acute suppurative, 198. 

chronic, 196. 

phlegmonous, 198. 

toxic, 199. 
Gastrodynia, 209. 
Gastrorrhagia, 208. 
Genickkrampf, 30. 
Giddiness, 211. 
Gingivitis ulcerosa, 167. 
Glioma, 398. 
Globus hystericus, 352. 
Glossitis, 171. 
Glottis, oedema of, 301. 
spasm of, 304. 
Glucose, Fehling's volumetric test, 
116. 

fermentation test, 116. 

qualitative tests for, 264. 

quantitative tests for, 116. 
Glucosuria, 114. 

functional, 117. 
Gluteal reflex, 345. 
Goiter, exophthalmic, 137. 
Gout, 105. 

acute, 105. 
chronic, 106. 
Graphospasm, 363. 
Gravel, 279. 
Green-sickness, 150. 
Grippe, the, 24. 

Haematemesis, 208. 
Haematuria, 287. 
Haemophilia, 160. 
Haemoptysis, 319. 
Hallucination, 402. 
Haut mal, 348. 
Hav asthma, 298. 

" fever, 298. 
Head, cold in the, 295. 

hydrocephalic, 389. 

rachitic, 108. 
Headache, sick, 358. 
Heart, the, 119. 

dilatation of, 124. 



Heart, the, diseases of, 119. 

fatty degeneration of, 

126. 
fatty infiltration of, 127. 
hypertrophy of, 122. 
inflammation of, 127. 
neuralgia of, 136. 
palpitation of, 135. 
rupture of, 127. 
valvular diseases of , 130 
Heart-burn, 210. 
Heart-failure, 329. 
Heat-stroke, 400. 
Hemichorea, 347. 
Hemicrania, 358. 
Hemiplegia, 394. 
Hemorrhage, bronchial, 319. 
cerebral, 393. 
from mouth, 174. 
gastric, 208. 
intestinal, 231. 
pulmonary, 319. 
Hepatic cancer, 253. 

colic, 258. 
Hepatitis, acute, 248. 

interstitial, 250. 
suppurative, 248. 
Hepatization of lung, 329. 
Herpes zoster, 356. 
Homoeopathic treatment, 10. 
Hooping-cough, 81. 
Hydatids of kidney, 282. 

liver, 254. 
Hydrocephalus, 388. 

acquired, 388. 
acute, 386. 
chronic, 388. 
congenital, 389. 
Hydronephrosis, 275. 
Hydropericardium, 141. 
Hydrophobia, 87. 
Hydrothorax, 341. 
Hygiene, 22. 

Hyperaemia, cerebral, 390. 
hepatic, 247. 
pulmonary, 321. 
renal, 267. 
spinal, 373. 
splenic, 261. 
Hyperaesthesia, 343. 
Hyperalgesia, 343. 
Hyperpyrexia, 17. 
Hypertrophy, cardiac, 122. 



INDEX. 



427 



Hypertrophy, compensatory, 123. 

gastric, 207. 

of "bladder, 284. 
stomach, 207. 

splenic, 262. 
Hypodermoclysis, 77. 
Hysteria, 352. 
Hystero-epilepsy, 350. 

Ice-bags, 23. 
Ice in hyperpyrexia, 23. 
Ichthyol ointment, 81. 
Icterus, 246. 

neonatorum, 247. 
Idiocy, 414. 
Ileo-colitis, 224. 
Illusion, 402. 
Imbecility, 414. 
Incoordination, 303. 
Incubation, period of, 8, 20. 
Indigestion, acute, 193. 

stomachic, 210. 
Induration, fibroid, 207. 
gastric, 207. 
Infantile paralysis, 377. 
Infection, mixed microbic, 40. 
Infectious diseases, 73. 
Influenza, 24. 

Russian, 24. 
Inoculation for hydrophobia, 89. 

variola, 58. 
Insane, general paralysis of, 417. 
Insanity, 402. 

affective, 404. 
circular, 413. 
emotional, 404. 
ideational, 404. 
impulsive, 405. 
intellectual, 404. 
moral, 414. 
pathetic, 404. 
protopathic, 409. 
raving, 407. 
Insolation, 400. 
Insomnia, 407. 
Inspection, 290. 
Insufficiency, aortic, 131. 
mitral, 130. 
pulmonic, 133. 
tricuspid, 132. 
valvular, 130. 
Intermittent fever, 47. 
Intestines, diseases of, 213. 



Introduction, 7. 
Intussusception, 230. 
Invagination of intestines, 230. 
Invasion, period of, 20. 
Isolation, 21. 

Jail fever, 32. 
Jaundice, 246. 

catarrhal, 257. 

hematogenous, 246. 

hemorrhagic, 255. 

hepatogenous, 246. 

malignant, 255. 

Kakke, 101. 

Kathode, 343. 

Kidney, albuminoid, 273. 

amyloid, 273. 

cancer of, 278. 

colic, 280. 

congestion of, 267. 

contracted, 271. 

diseases of, 266. 

dropsy of pelvis of, 275. 

floating, 277. 

gouty, 271. 

hydatids of, 282. 

inflammation' of pelvis of, 
274. 

lardaceous, 273. 

large white, 270. 

movable, 277. 

stones, 279. 

tuberculosis of, 278. 

waxy degeneration of, 273. 
Kinks, 304. 
Koch, bacillus tuberculosis of, 91. 

comma bacillus of, 75. 
Koch's lymph, 97. 

La grippe, 24. 
Landry's palsy, 378. 
Laryngismus stridulus, 304. 
Laryngitis, acute catarrhal, 300. 

chronic, 302. 

croupous, 307. 

diphtheritic, 307. 

membranous, 307. 

oedematous, 301. 

pseudo - membranous, 
307. 

tubercular, 303. 
Laryngospasm, 304. 



428 



INDEX. 



Larynx, diseases of, 300. 
Leptomeningitis, acute spinal, 372. 
chronic spinal, 
374. 
Leucaemia, 151. 

lymphatica, 152. 
myelogenica, 152. 
splenic, 152. 
Leucocythsemia, 151. 
Leucocytosis, 152. 
Lightheadedness, 211. 
Line, gingival, 95. 
Liver, abscess of, 248. 

acute parenchymatous degen- 
eration of, 255. 
yellow atrophy of, 255. 
albuminoid, 252. 
amyloid, 252. 
cancer of, 253. 
cirrhosis of, 250. 
congestion of, 247. 
diseases of, 245. 
fatty degeneration of, 253. 
gin-drinkers', 250. 
hob-nailed, 250. 
hydatids of, 254. 
lardaceous, 252. 
nutmeg, 248. 
scrofulous, 252. 
stones, 258. 
syphilitic, 251. 
waxy, 252. 
Lockjaw, 86. 
Locomotor ataxia, 380. 
Lumbago, 103. 
Lumbodynia, 103. 
Lunacy, 402. 

Lungs, atelectasis of, 322. 
cirrhosis of, 333. 
congestion of, 321. 
diseases of, 311. 
oedema of, 321. 
tuberculosis of, 94. 
Lymph, Koch's, 97. 
Lympho-sarcoma, 152. 
Lypemania, 412. 
Lysis, 9, 18. 

Madness, raving, 407. 
Mai, haut, 348. 

le grand, 348. 

le petit, 348. 
Malaria, 46. 



Malaria, acute, 47. 

chronic, 50. 
masked, 48. 
pernicious, 49. 
treatment of, 52. 
Malarial fevers, 46. 
Malasma suprarenale, 162. 
Malignant intermittent fever, 49. 
jaundice, 255. 
pustule, 89. 
remittent fever, 49. 
sore throat, 77. 
Malingering, 350. 
Mania, 405. 

acute, 407. 

delirious, 405. 
chronic, 408. 
Marsh fever, 48. 
Measles, 64. 

black, 65. 
false, 67. 
French, 67. 
German, 67. 
hemorrhagic, 65. 
malignant, 65. 
Medication, internal, in fevers, 22. 
Medicine, practice of, 8. 
science of, 7. 
Mediterranean fever, 44. 
Megrim, 358. 
Melaena, 208. 
Melansemia, 51. 
Melancholia, 412. 

attonita, 413. 
hypochondriacal, 412. 
Melituria, 114. 
Membrane, false, 78. 
Meningitis, acute cerebral, 385. 
spinal, 372. 
basilar, 386. 
chronic spinal, 374. 
epidemic cerebro-spinal, 

30. 
hysterical, 31. 
tubercular, 386. 
Mensuration, 290. 
Mercurialism, 175. 
Metastasis, 84. 
Micrococcus erysipelatis, 71. 

intracellularis menin- 
gitidis, 32. 
pneumoniee, 328. 
Migraine, 358. 



INDEX. 



429 



Milk, preparation of, 223. 
Mind, 402. 
Mogigraphia, 363. 
Monomania, 409. 
Morbilli, 64. 
Motion, 343. 

Month, abscess of floor of, 187. 
cancer in, 174. 
catarrh of, 164. 
diphtheria of, 167. 
diseases of, 164. 
gangrene of, 172. 
hemorrhage from, 174. 
inflammation of, 164. 
nlcers of, 168. 
white, 169. 
Mucus, test for, 265. 
Muguet, 169. 
Mumps, 84. 
Murmurs, cardiac, 121. 

diastolic, 121. 
functional, 121. 
organic, 121. 
presystolic, 131. 
systolic, 121. 
hsemic, 130. 
table of cardiac, 121. 
vesicular, 292. 
Myalgia, 103. 
Myelitis, acute, 375. 

anterior cornual, 377. 
chronic, 379. 
diffuse, 376. 
focal, 376. 
Myocarditis, 127. 
Myotonia, congenital, 354. 

Nackenstarre, 30. 

Nephritis, acute desquamative, 268. 
tubal, 268. 
chronic desquamative, 

269. 
chronic interstitial, 271. 

tubal, 269. 
parenchymatous, 268, 

269. 
peri-, 276. 
pyelo-, 274. 
Nephro-lithiasis, 279. 
Nerve-action, reflex, 342. 
Nerves, diseases of, 365. 
Nervous system, the, 342. 
Neuralgia, 354. 



Neuralgia, cervico-brachial, 356. 
occipital, 356. 
intercostal, 356. 
lumbo-abdominal, 356. 
of heart, 136. 
intestines, 232. 
stomach, 209. 
trifacial, 355. 
Neurasthenia, 362. 
Neuritis, 365. 

ascendens, 366. 
chronic, 367. 
descendens, 366. 
disseminated, 367. 
multiple, 367. 
optic, 399. 
peripheral, 367. 
Neuroses, the, 346. 
Neurosis, 346. 
Night-sweats, 94. 
Noma, 172. 

Non-infectious diseases, 103. 
Nose, acute catarrh of, 295. 

chronic catarrh of, 296. 
diseases of, 295. 
Nystagmus, 346, 382. 

Obstruction, aortic, 132. 

intestinal, 230. 

mitral, 131. 

pulmonic, 133. 

pyloric, 206. 

tricuspid, 133. 
(Edema of glottis, 301. 
lungs, 321. 
Oesophagitis, 190. 
(Esophagus, dilatation of, 191. 

diseases of, 189. 

stricture of, 190. 
Oidium albicans, 170. 

lactis, 170. 
Oposthotonos, 31. 
Oreillous, 84. 
Orthotonos, 31. 
Oxyuris vermicularis, 237. 
Ozena, 297. 

Pachymeningitis, cerebral, 388. 
spinalis, 375. 
Palpation, 291. 
Palpitation, cardiac, 135. 
Palsy, BelPs, 370. 

Landry's 378. 



430 



INDEX. 



Palsy, shaking, 360. 
writers', 363. 
Pancreas, cancer of, 244. 

diseases of, 244. 
Pancreatitis, 244. 
Pantophobia, 412. 
Papoicl, 197. 
Paralysis, acute spinal, 377. 

of adults, 
377. 
agitans, 360. 
ascendens, acuta, 378. 
atrophic spinal, 377. 

chronic dif- 
fused, 379. 
diphtheritic, 79. 
essential, of children, 377. 
facial, 370. 

general, of insane, 417. 
Landry's, 378. 
of bladder, 287. 
Paranoea, 409. 
Paraplegia, 376. 
Parasites, intestinal, 235. 

renal, 281. 
Paresis, 365. 
Parkinson's disease, 260. 
Parotitis, 84. 

idiopathic, 84. 
symptomatic, 84. 
Pasteur's virus, 89. 
Pathology, 9. 
Pectoriloquy, 294. 
Percussion, 291. 

respiratory, 292. 
Pericarditis, acute, 139. 
chronic, 140. 
dry, 140. 
Pericardium, diseases of, 139. 
Perinephritis, 276. 
Perineuritis, 365. 
Periproctitis, 219. 
Peritoneum, diseases of, 239. 
Peritonitis, 239. 
Perityphlitis, 216. 
Pertussis, 81. 
Petit mal, 348. 
Pharyngitis, acute, 177. 
chronic, 179. 
follicular, 179. 
herpetic, 180. 
phlegmonous, 181. 
sicca, 181. 



Pharyngitis, tubercular, 180. 
Pharynx, catarrh of, 177. 
diseases of, 177. 
herpes of, 180. 
syphilis of, 185. 
Phlebitis, 144. 
Phosphates, tests for, 265. 
Phthisis, acute, 92. 

chronic, 94. 
fibroid, 333. 
laryngeal, 303. 
miner's, 333. 
pneumonic, 332. 
tubercular, 94. 
Pill acetanilide comp., 27. 
Plague, bubonic, 35. 

Levantine, 35. 
Oriental, 35. 
the, 35. 
Plantar reflex, 345. 
Pleura, diseases of, 335. 
Pleurisy, acute, 335. 

chronic, 338. 
dry, 336. 
Pleuritis, acute, 335. 

chronic, 338. 
Pleurodynia, 103. 
Pleuro-pneumonia, 330. 
Pneumonia, 328. 

caseous, 332. 
catarrhal, 316. 
chronic, 332. 
croupous, 328. 
lobar, 328. 
lobular, 316. 
scrofulous, 332. 
typhoid, 329. 
Pneumonitis, 328. 
Pneumothorax, 340. 
Poliomyelitis anterior acuta, 377. 

chronic, 379. 
Polya?sthesia, 343. 
Polyneuritis, 367. 
Polyuria, 113. 
Pox, 98. 

Predisposition, 8. 
Prevention of contagion, 21. 
Proctitis, 217. 

chronic, 218. 
Prognosis, 10. 
Prophylaxis of contagious diseases, 

21. 
Pseudo-leucaemia, 152, 



INDEX. 



431 



Psychoses, 402. 

Psychrophobia, 89. 

Ptomaine, 20. 

Ptyalism, 175. 

Pulmonic insufficiency, 133. 

stenosis, 133. 
Pulse, Corrigan's, 131. 
dichrotic, 331. 
water-hammer, 131. 
Pupil, Argyll-Robertson, 381. 
Purpura, 158. 

hsemorrhagiea, 158. 

rheumatica, 158. 

simplex, 158. 

urticans, 158. 
Pustule, malignant, 89. 
Putrid fever, 32. 
Pyaemia, 156. 
Pyelitis, 274. 
Pyelonephritis, 274. 
Pylephlebitis, adhesive, 256. 

suppurative, 256. 
Pyonephrosis, 275. 
Pyrexia, 17. 
Pyrosis, 210. 

Quinsy, 181. 

acute, 181. 
blind, 182. 
chronic, 182. 

Rabies, 87. 
Rachitis, 107. 
Rales, 293. 

Reaction of degeneration, 344. 
Reactions, electrical, 343. 
Rectitis, 217. 
Rectum, catarrh of, 217. 
Reflex, abdominal, 345. 
cremasteric, 345. 
gluteal, 345. 
plantar, 345. 
scapular, 345. 
Reflexes, 345. 

cutaneous, 345. 
tendon, 345. 
Regurgitation, aortic, 131. 
mitral, 130. 
piilmonic, 133. 
tricuspid, 132. 
Resonance, vocal, 294. 
Respiration, 293. 

Cheyne-Stokes, 293. 



Respiration, puerile, 292. 
Rheumatism, acute, 109. 

gonorrhceal, 113. 
inflammatory, 109. 
muscular, 103. 
Rhinitis, acute, 295. 

chronic, 296. 

dry, 297. 

moist, 297. 
Ribs, beaded, 108. 
Rickets, 107. 
Risus sardonicus, 86. 
Rosary, rickety, 108. 
Rose, the, 69. 
Rose-cold, 299. 
fever, 299. 
Roseola, 67. 
Rotheln, 67. 
Rubella, 67. 
Rubeola, 67. 

Salivation, 175. 
Saprasmia, 153. 
Scapular reflex, 345. 
Scarlatina, 60. 

anginosa, 62. 
maligna, 62. 
simplex, 61. 
Scarlet fever, 60. 
Sciatica, 368. 

Sclerosis, antero-lateral spinal, 379. 
cerebro-spinal, 382. 
disseminated, 382. 
insular, 382. 
multiple spinal, 382. 
posterior spinal, 380. 
spinal, 379. 
Scorbutus, 159. 
Scurvy, infantile, 159. 
land, 158. 
sea, 159. 
Sensation, 343. 
Senses, localization of, 342. 
Septicaemia, 154. 
Shaking palsy, 360. 
Ship fever, 32. 
Sickness, green, 150. 
Side, stitch in the, 103. 
Signs, physical, 289. 
Smallpox, 55. 

black, 55. 
confluent, 57. 
discrete, 56. 



432 



INDEX. 



Softening of the brain, 392, 393. 
Sore throat, clergymen's, 179. 

syphilitic, 99. 
Spinal cord, diseases of, 372. 

inflammation of, 375. 
meningitis, 372. 
Spirillum cholerae, 73. 
Spirochete Obermeieri, 29. 
Spirometer, 290. 
Spleen, amyloid, 262. 

congestion of, 261. 
diseases of, 261. 
hypersemia of, 261. 
hypertrophy of, 262. 
Splenification, 322. 
Splenitis, 261. 
Sponging, cold, 22. 
Spotted fever, 30. 
Sprew, 169. 
St. Anthony's fire, 69. 
St. Vitus's dance, 346. 
Static electricity, 344. 
Stenosis, aortic, 132. 
mitral, 131. 
pulmonic, 133. 
pyloric, 206. 
tricuspid, 133. 
valvular, 130. 
Stomach, cancer of, 203. 
catarrh of, 193. 
cirrhosis of, 207. 
dilatation of, 206. 
diseases of, 193. 
hemorrhage from, 208. 
hypertrophy of, 207. 
neuralgia of, 209. 
Stomach, ulcer of, 200. 
Stomatitis, 164. 

aphthous, 166. 
chronic, 164. 
croupous, 166. 
erythematous, 164. 
follicular, 166. 
parasitic, 169. 
simple, 164. 
ulcerative, 167. 
vesicular, 166. 
Stools, rice-water, 74. 
Streptococcus pyogenes, 156. 
Strychnine in tuberculosis, 96. 
Stupid fever, 32. 
Succussion, 294. 
Sugar, qualitative tests for, 264. 



Sugar, quantitative tests for, 116. 
Summer complaint, 222. 
diarrhoea, 224. 
Sun-stroke, 400. 

Suprarenal capsule diseases, 162. 
Symptoms, 9. 

objective, 9. 
pathognomonic, 9. 
prodromal, 9. 
subjective, 9. 
Synache maligna, 77. 
Syncope, 211. 
Synochus, 23. 
Synonyms, 8. 
Syphilis, 98. 

cerebral, 100. 
hepatic, 251. 
pharyngeal, 185. 
System, the nervous, 242. 

sympathetic, 242. 
Systole, 120. 

Tabes dorsalis, 380. 
Taenia echinococcus, 254. 

medioeanellata, 235. 
saginata, 235. 
solium, 236. 
Tape-worm, 236. 
Temperature, 17. 

rectal, 18. 
Tendon reflex, 345. 
Tests for albumin, 263. 
bile, 265. 
chlorides, 265. 
hydrochloric acid, 204. 
lactic acid, 204. 
mucus, 265. 
phosphates, 265. 
sugar, 264. 
uric acid, 265. 
Tetanus, 86. 

idiopathic, 86. 
neonatorum, 86. 
traumatic, S6. 
Throat, acute sore, 177. 

clergymen's sore, 179. 
follicular sore, 179. 
malignant sore, 77. 
putrid sore, 77. 
Thrombosis, cerebral, 396. 
Thrush, 169. 
Tic-doulouroux, 355. 
Tongue, inflammation of, 171. 



INDEX. 



433 



Tongue, psoriasis of, 171. 
Tonsilitis, acute, 181. 

chronic, 182. 
Tonsils, herpes of, 186. 

hypertrophy of, 182. 
inflammation of, 181. 
Tophi, 106. 
Tormina, 232. 
Treatment, 10. 

alkaline, 112. 
Trichocephalus dispar, 235. 
Tricuspid insufficiency, 132. 

stenosis, 133. 
Trismus, 86. 
Tropseolin paper, 204. 
Trophic changes, 344. 
Tuberculin, 97. 
Tuberculosis, 91. 

acute, 92. 
chronic, 94. 
external, 91. 
internal, 91. 
laryngeal, 303. 
medical, 91. 
miliary, 92. 
pulmonary, 94. 
renal, 278. 
staining of bacillus, 

92. 
surgical, 91. 
Tumors, cerebral, 398. 
Typhlitis, 215. 
Typhoid fever, 37. 

walking, 40. 
Typhomalaria, 49. 
Typhomania, 405. 
Typhus, 32. 

abdominal, 37. 
apoplectic cerebral, 30. 
cerebrospinal, 30. 
icterodes, 44. 

Ulcers, duodenal, 214. 
gastric, 200. 
of intestine, 229. 
mouth, 168. 
rectum, 218. 



Ulcers, phagedenic, 173. 

syphilitic, 99, 169. 
Uraemia, 266. 
Urine, 263. 

composition of, 263. 

incontinence of, 286. 

retention of, 288. 
Uvula, elongated, 179. 

Vaccination, 58. 
Valvular diseases, 130. 
Varicella, 54. 
Variola, 55. 

confluent, 57. 

discrete, 56„ 

hemorrhagic, 57. 

malignant, 57. 

mitigated, 57. 
Varioloid, 57. 
Vermiform appendix, inflammation 

of, 215. 
Vertigo, epileptic, 348. 

stomachic, 211. 
Voice, the, 294. 
Vomit, coffee-ground, 204. 
faecal, 230. 

Wet-pack, 23. 
Whooping-cough, 81. 
Winter cough, 314. 
Worms, intestinal, 235. 

round, 236. 

seat, 237. 

tape, 236. 

thread, 237. 
Writers' cramp, 363. 

palsy, 363. 
Wry-neck, spasmodic, 104. 
Wunderlich, ambiguous period of, 
39. 

Yellow fever, 44. 
Jack, 44. 

Ziegenpeter, 84. 
Ziehl's solution, 92. 



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